Studies on the time frame for ossification of the medial clavicular epiphyseal cartilage in conventional radiography

Methods of Assessing Skeletal Maturity When Planning Surgeries About the Knee

Increased participation in youth sports has led to more knee injuries necessitating surgical intervention. Among the youngest athletes, such procedures typically involve physeal-respecting techniques for anterior cruciate ligament reconstruction, medial patellofemoral ligament reconstruction for patellar instability, osteochondritis dissecans fixation, and implant-mediated guided growth procedures. In each case, the choice of appropriate intervention is critically dependent on a patient's skeletal maturity. Compared with chronologic age, skeletal age accounts for individual maturation and is the benchmark for determination of development in orthopaedics. This is historically assessed using the Greulich and Pyle method, in which bone age is determined through comparison of a patient's hand radiograph with the closest standard radiograph from an atlas of American children from the early 1900s. In the setting of knee pathology, obtaining additional imaging requires further radiation and time. Several bone age determination methods exist incorporating radiographic characteristics of the distal femur, proximal tibia, and/or proximal fibula. This study therefore sought to review available methods for determination of skeletal age when planning surgeries about the knee using readily available, routine knee imaging. The review focuses on both radiograph and MRI-based skeletal maturity staging systems that surgeons may use to guide appropriate treatment while describing the strengths and weaknesses of each method.

Magnetic resonance imaging for multi-factorial age estimation using Bayes' rule: a validation study in two independent samples

OBJECTIVES

Multi-factorial age estimation (MFA) models have been developed based on Bayes' rule, combining MRI data of the third molars (T), left wrist (W) and/or both clavicles (C). Internal cross-validated performance was reported, but external validation is needed before bringing the approach into practice. This study aimed to validate these MFA models in two independent samples.

METHODS

In the Ghent sample, W + C MRI was prospectively conducted in 108 healthy Caucasian volunteers (52 males, 56 females) aged 16 to 21 years. In the Graz sample, T + W + C MRI was prospectively conducted in 335 healthy Caucasian males aged 13 to 24 years. Development was staged and checked for intra-observer reliability, and age estimation performances were tested.

RESULTS

Staging clavicles was most prone to intra-observer variability. Applying the W + C model to Ghent males rendered a mean absolute error of 1.55 years, a root mean square error of 1.90 years, 70.6% correctly categorised adults and 94.4% correctly categorised minors. In females, the results were 1.49 years, 1.83 years, 92.1% and 66.7%, respectively. Regarding the Graz sample, the W + C results were 1.66 years, 2.08 years, 94.7% and 80.7%, respectively. For the T + W + C model, the results were 1.41 years, 1.80 years, 95.2% and 81.5%, respectively.

CONCLUSION

The T + W + C and W + C models rendered a similar accuracy of the point prediction of age in both validation samples. However, they bared a larger risk of wrongfully categorising a minor as an adult than reported for internal validation, stressing the importance of the prediction interval for age estimation in practice.

Outcome and Femoral Head Deformity Following Hip Guided Growth in Children With Cerebral Palsy at Skeletal Maturity

BACKGROUND

Guided growth of the proximal femur, a minimally invasive procedure for coxa valga, shows promising short-term outcomes in cerebral palsy (CP). However, as it alters physis growth, existing studies lack comprehensive long-term analysis until skeletal maturity.

METHODS

This retrospective study included children with spastic CP who underwent proximal femur-guided growth surgery between 2012 and 2017, followed until physeal closure. Radiographic measurements included head-shaft angle (HSA), Hilgenreiner-epiphyseal angle (HEA), acetabular index (AI), Reimer's migration percentage (MP), and α angle. Outcomes were compared between ambulatory/nonambulatory (GMFCS I-III/IV, V) and with/without soft tissue release. Factors associated with earlier physeal closure and femoral head deformity were analyzed.

RESULTS

Among 29 patients (53 hips) with guided growth studied at skeletal maturity, 4 patients (6 hips, 11.3%) experienced procedure failure and required varus osteotomy due to severe deformities. It was more common in GMFCS IV-V patients (27.3%, 3/11) than in GMFCS I-III (5.6%, 1/18). In the remaining 25 patients (47 hips), 7 hips (14.9%) received concomitant pelvic osteotomy with AI and MP evaluated separately. All radiographic parameters improved significantly (P<0.001). Epiphysis grew off the screw in 25 hips (53.2%), requiring reinsertion in 19 (40.4%), with a higher rate in nonambulatory children (73.3% vs. 25%, P=0.002). Changes of the parameters showed no difference between ambulatory/nonambulatory (GMFCS I-III/IV, V) and with/without soft tissue release. The cumulative duration of screw crossing the physis was a key factor for earlier closure (P<0.001) and correlated with increased α angle (P=0.039).

CONCLUSION

Guided growth successfully improved outcomes in both ambulatory and nonambulatory groups, although less effective in severe dysplasia. This minimally invasive procedure has some concerns, including the epiphysis growing off the screw, reinsertion need, earlier physeal closure, and femoral head deformity.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Charting the growth through intelligence: A SWOC analysis on AI-assisted radiologic bone age estimation

Bone age estimation (BAE) is based on skeletal maturity and degenerative process of the skeleton. The clinical importance of BAE is in understanding the pediatric and growth-related disorders; whereas medicolegally it is important in determining criminal responsibility and establishing identification. Artificial Intelligence (AI) has been used in the field of the field of medicine and specifically in diagnostics using medical images. AI can greatly benefit the BAE techniques by decreasing the intra observer and inter observer variability as well as by reducing the analytical time. The AI techniques rely on object identification, feature extraction and segregation. Bone age assessment is the classical example where the concepts of AI such as object recognition and segregation can be used effectively. The paper describes various AI based algorithms developed for the purpose of radiologic BAE and the performances of the models. In the current paper we have also carried out qualitative analysis using Strength, Weakness, Opportunities and Challenges (SWOC) to examine critical factors that contribute to the application of AI in BAE. To best of our knowledge, the SWOC analysis is being carried out for the first time to assess the applicability of AI in BAE. Based on the SWOC analysis we have provided strategies for successful implementation of AI in BAE in forensic and medicolegal context.

CT-assisted age estimation from the medial clavicular epiphysis in the Greek population according to Schmeling and Kellinghaus classification

Examining the clavicle by macroscopic or radiologic techniques is a well-established method in forensic age estimation in living and dead individuals. The present study examined 196 CT (computed tomography scan) images of native patients from the archive of the medical imaging laboratory of the University Hospital in Heraklion, Crete, in Greece. The ossification of the medial clavicular epiphysis was classified according to Schmeling et al. and the extended amplified staging system of Kellinghaus et al. Next, a stage transition analysis was carried out according to the Bayesian model. Probability density functions were calculated using informative priors for age distribution in the total population, deceased and violently deceased individuals. Our study showed that when the medial clavicular epiphysis' ossification is sorted in stages 4 and 5 in Greek males and females, the cumulative probability of adulthood (≥18 years) is nearly 1. As far as Greek males are concerned, in stage 3c, the cumulative probability of adulthood (≥18 years) is 0.86, and in Greek females in stage 3c, the cumulative probability of adulthood (≥18 years) is 0.97. This is the first study of age estimation based on the ossification of the sternal clavicular end using CT in a Greek population.

Bone age and dental age to assess criminal responsibility: Part II

INTRODUCTION

Age estimation is vital in dentistry and legal contexts to determine minors' criminal responsibility. This study aimed to estimate and classify bone and dental age in a Portuguese population, using the Greulich-Pyle method and the Moorrees Fanning and Hunt method, comparing the accuracy of both methods.

MATERIALS AND METHODS

597 left hand and wrist radiographs and 184 orthopantomographs were selected, and the methods were applied.

RESULTS

Cohen's weighted kappa coefficient ranged between 0.890 and 1. Both methods underestimate age. The linear regression formulas showed strong correlations between estimated and real age (0.902 for bone age assessment and 0.894 for dental age assessment). For the bone assessment the accuracy is highest at 14 and 18 years, with similar values to those at 12 and 16. The AUC shows that the method is more reliable at 12 and 14 years. For the dental age assessment, a lower sensitivity value was observed for the age of 12 (73.91%) and a higher for 18 years (91.03%), increasing with age. The accuracy was higher at 12 years (89.62%) and lowest at 18 years (83.02%). Specificity values were higher for ages 12 and 14 (93.98% and 95.24%, respectively). The lowest AUC value was recorded for 18 years (0.889), while for ages 12, 14, and 16, the values were similar, indicating lower reliability for the legal age of 18.

CONCLUSION

For individuals under 12, 14, 16, and 18 years old, the bone method is the most effective. However, combining both methods allows greater accuracy and consistency in age estimation for medico-legal applications.

Forensic age estimation using Vieth classification in adolescents of northern China based on the knee MRI

To investigate the applicability of the Vieth classification and characteristics of ossification age in knee joint in adolescents of northern China. A retrospective study was conducted on a total of 1517 MRI images of knee joints from patients aged 10 to 20 years in the northern China. Vieth classification was used to assess the ossification age of distal femur and proximal tibia. Descriptive analysis was performed to obtain the maximum, minimum, median, and upper and lower quartiles of age at each stage, stack bar graph were used to show the age distribution at each stage. Mann-Whitney U test was utilized to analyze the differences in the stage of the proximal tibia and distal femur. Good intra-observer and inter-observer consistency (к = 0.89 and 0.88) was obtained. Regarding the distal femoral epiphysis, 100% of male participants in stage 3, 4(and 5) and 6 were over 12, 14 and 16 years old, respectively; 100% of female participants in stage 4, 5 and 6 were over 12, 14 and 16 years old. While for proximal tibial epiphysis, 100% of male participants in stage 4 and 5 were over 12 and 14 years old; 100% of female participants in stage 4 and 5 were over 12 years old. Ossification age of the proximal tibia mature earlier than distal femur (P < 0.001). Vieth classification can be used to infer the age of 12, 14 and 16 years in adolescents of northern China, providing a valuable reference for forensic age estimation.

Bone Age Assessment Using Various Medical Imaging Techniques Enhanced by Artificial Intelligence

Bone age (BA) reflects skeletal maturity and is crucial in clinical and forensic contexts, particularly for growth assessment, adult height prediction, and managing conditions like short stature and precocious puberty, often using X-ray, MRI, CT, or ultrasound imaging. Traditional BA assessment methods, including the Greulich-Pyle and Tanner-Whitehouse techniques, compare morphological changes to reference atlases. Despite their effectiveness, factors like genetics and environment complicate evaluations, emphasizing the need for new methods that account for comprehensive variations in skeletal maturity. The limitations of classical BA assessment methods increase the demand for automated solutions. The first automated tool, HANDX, was introduced in 1989. Researchers now focus on developing reliable artificial intelligence (AI)-driven tools, utilizing machine learning and deep learning techniques to improve accuracy and efficiency in BA evaluations, addressing traditional methods' shortcomings. Recent reviews on BA assessment methods rarely compare AI-based approaches across imaging technologies. This article explores advancements in BA estimation, focusing on machine learning methods and their clinical implications while providing a historical context and highlighting each approach's benefits and limitations.

A probability model for estimating age in young individuals relative to key legal thresholds: 15, 18 or 21-year

Age estimations are relevant for pre-trial detention, sentencing in criminal cases and as part of the evaluation in asylum processes to protect the rights and privileges of minors. No current method can determine an exact chronological age due to individual variations in biological development. This study seeks to develop a validated statistical model for estimating an age relative to key legal thresholds (15, 18, and 21 years) based on a skeletal (CT-clavicle, radiography-hand/wrist or MR-knee) and tooth (radiography-third molar) developmental stages. The whole model is based on 34 scientific studies, divided into examinations of the hand/wrist (15 studies), clavicle (5 studies), distal femur (4 studies), and third molars (10 studies). In total, data from approximately 27,000 individuals have been incorporated and the model has subsequently been validated with data from 5,000 individuals. The core framework of the model is built upon transition analysis and is further developed by a combination of a type of parametric bootstrapping and Bayesian theory. Validation of the model includes testing the models on independent datasets of individuals with known ages and shows a high precision with separate populations aligning closely with the model's predictions. The practical use of the complex statistical model requires a user-friendly tool to provide probabilities together with the margin of error. The assessment based on the model forms the medical component for the overall evaluation of an individual's age.

T2-weighted spoiled gradient echo MRI for forensic age estimation: a study on knee growth plates

The timing of growth plate fusion is a key indicator for age estimation and is primarily used in forensic investigations. On the other hand, non-ionizing techniques such as MRI are being developed to provide safer and more ethical evaluations in forensic casework. This study aims to evaluate the closure process of growth plates in the distal femoral and proximal tibial epiphyses using Multiple Echo Recombined Gradient Echo (MERGE) MRI sequences and provide age estimation data based on staging methods for forensic purposes. We retrospectively analyzed 559 patients (294 males, 265 females, aged 8-25 years) diagnosed with trauma and knee pain at Tepecik Training and Research Hospital from 2016 to 2019. MRI scans were performed using a 1.5-T system with MERGE sequences and evaluated by two observers using a new staging system. Observer agreement was assessed using Cohen's κ test, yielding high agreement values (κ > 0.8). Positive correlations were found between age and ossification stages (p < 0.001). Minimum age thresholds for stages 5a and 5b of the distal femoral epiphysis were 16 and 18 years for females and 17 and 19 years for males, respectively. For the proximal tibial epiphysis, the minimum ages for stages 5a and 5b were 15 years for females and 17 years for males. The MERGE sequence provides a viable method for assessing skeletal maturity in living individuals with significant ethical advantages due to non-ionizing radiation. This study supports the potential application of the MERGE sequence in forensic age estimation, demonstrating high observer agreement and consistency. Future research should focus on comparing different sequences and populations to enhance the methodology's applicability.

Classifying age from medial clavicle using a 30-year threshold: An image analysis based approach

This study aimed to develop image-analysis-based classification models for distinguishing individuals younger and older than 30 using the medial clavicle. We extracted 2D images of the medial clavicle from multi-slice computed tomography (MSCT) scans from Clinical Hospital Center Split (n = 204). A sample was divided into a training (164 images) and testing (40 images) dataset. The images were loaded into the Orange Data Mining 3.32.0., and transformed into vectors using the pre-trained neural network Painters: A model trained to predict painters from artwork images. We conducted Principal Components Analysis (PCA) to visualize regularities within data and reduce data dimensionality in classification. We employed three classifiers that provided >80% accuracy: Support Vector Machine (SVM), Logistic Regression (LR), and Neutral Network Identity SGD (NNI-SGD). We used 5-fold cross-validation (CV) to obtain optimal variables and performances and validated data on the independent test set, with a standard posterior probabilities (pp) threshold of 0.5 and 0.95. The explainability of the model was accessed visually by analyzing clusters and incorrectly classified images using anthropology field knowledge. Based on the PCA, clavicles clustered into categories under 30 and 40 years, between 40 and 55 years, and over 80 years. The overall accuracy with standard pp ranged from 82.5% to 92.5% for CV and 82.5% to 92.5% for the test set. The posterior probability of 0.95 provided classification accuracy up to 100% but with a lower proportion of images that could be classified. The study showed that image analysis based on a pre-trained deep neural network could contribute to distinguishing clavicles of individuals younger and older than 30.

Forensic age estimation of adolescents using computed tomography of the clavicles

In forensic age estimation, CT imaging of the clavicles is used to determine an age over completed 21 years. If ossification of the medial clavicular epiphysis is complete, young men are assumed to be over 21 years of age. The aim of this study is to check the statistical parameters (specificity, predictive probability) for the characteristic "completed ossification of the medial clavicles". 285 male patients who, for various reasons, received a chest CT at the Medical Center of the University of Freiburg between 1st December 2019 and 6th December 2022 were screened for the study, of whom 203 patients were included in the study. The stage of clavicular ossification was classified as stage 1 - 5 according to Schmeling. While 70 out of 71 patients under 21 years of age were correctly estimated to be under 21 years of age, there was one patient whose ossification on one side was classified as stage 4 and who would therefore have been estimated to be over 21 years of age. If only subjects whose ossification stage was the same on both sides are included, the specificity of the test method is 100% and the positive predictive probability is 100%. If patients for whom only one side is stage 4 are also included, the specificity is 98.6%. Thus, only the complete and symmetrical ossification of both clavicles (stage 4 according to the Schmeling classification) in a standardised thin-layer CT can be classified as a reliable indicator of an age over 21 years in young men. In the case of asymmetric ossification of the medial clavicles (stage 4 is not reached on one side), false positive evaluations and the incorrect assumption of an age over 21 years can occur.

Forensic age estimation from ossification centres: a comparative investigation of imaging and physical methods

Age estimation is a crucial component of human identification in forensic science. It has a vital role in forensic anthropology, including examinations of skeletal remains, disaster victim identification, and locating missing individuals. Present communication focuses on the age estimation through the examination of ossification centers of bones and its significance in identifying the age of 18 years old, a recognized age of majority in many countries. The process of ossification is integral to biological development and serves as critical standard for age estimation in forensic identification. This study reviews relevant literature from well-known databases such as PubMed, Scopus, Web of Science, and ScienceDirect. Additionally, the present review elaborates various classification methods used by authors to classify the stages of ossification centers of bones. The objective of this communication is to assess the effectiveness of both imaging and physical methods for age estimation and to provide a critical comparison to determine the superior approach. The findings suggest that imaging methods are more reliable for the estimation of age from ossification centers. Staging methods introduced by Schmeling et al, Kellinghaus et al, Dedouit et al, Vieth et al, and Kvist et al. are found to be the best methods for age estimation.

Forensic Age Determination Using MRI Scans of the Ankle: Applying Two Classifications to Assess Ossification

In forensic age determination, e.g. for legal proceedings, exceeded age limits may be relevant. To investigate age-related differences in skeletal development, the recommendations of the Study Group on Forensic Age Diagnostics (AGFAD) rely on imaging techniques using ionizing radiation (including orthopantomograms and radiographs of the hand). Vieth et al. and Ottow et al. have proposed MRI classifications for epi-/diaphyseal fusion of the knee joint to determine different age limits. The aim of the present study was to verify whether these two classifications could also be applied to MRI of the ankle.MRI images of the ankle from 333 patients (160 female, 173 male) ranging in age from 10 to 28 years were retrospectively analyzed. T1-weighted turbo spin-echo (TSE) sequences and T2-weighted fat-suppressed sequences were analyzed for the two classifications. The different ossification stages of the two classifications were determined and the corresponding chronological ages were assigned. In addition, gender-specific differences were analyzed. Intra- and inter-observer variability was determined using Cohen's kappa.With the classification of Ottow et al., the completion of the 14th year of life could be determined in both sexes. With the classification of Vieth et al, the completion of the 14th year of life could be determined in both sexes and the 18th year of life in male patients. Intra-observer and inter-observer variability was very good and good, respectively (κ > 0.87 and κ > 0.72).In the present study, it was also possible to use both classifications for MRI of the ankle joint. The method offers the potential of an alternative or at least supplementary radiation-free assessment criterion in forensic age estimation. · MRI scans of the ankle can be used for forensic age determination.. · Classifications developed for the knee joint can also be used on the ankle.. · The applied classifications based on Vieth et al. and Ottow et al. can be used as an alternative or, at the least, an additional method when determining legally relevant age limits.. · Wernsing MF, Malokaj V, Kunz SN et al. Forensic Age Determination Using MRI Scans of the Ankle: Applying Two Classifications to Assess Ossification. Fortschr Röntgenstr 2024; DOI 10.1055/a-2379-8785.

Forensic age estimation at the University Center of Legal Medicine Lausanne-Geneva: a retrospective study over 12 years

With the undeniable increase in asylum requests from unaccompanied alleged minors, age estimation of living individuals has become an essential part of the routine work in European forensic centers. This study aims to review the forensic age estimations performed in our center since 2010, to evaluate the state-of-the-art of this practice in Switzerland with the evolution of the methodology according to upcoming recommendations. Our institute's expert reports performed between 2010 and 2022 were retrospectively analyzed. We gathered the following parameters: demographic data, morphological characteristics, alleged age compared with the assessed minimum age, sexual maturation, dental and bone age. When available, we collected personal and family history, medical history, records of torture-related/self-inflicted injuries, and information about eating habits that might affect skeletal development. Data collection amounted to 656 cases. Forensic age estimations ordered by the Swiss Secretariat for Migration (SEM) represented 76.4% of cases, with 23.6% of them ordered by the Court/Public Prosecutor. Most alleged minors were male (94.5%) and came from Afghanistan (53.4%). Adjunction of CT scans of the sternoclavicular joints was necessary in 86.4% of cases. Only 25.2% of our reports concluded on most probable minority, with 55.6% of definite majors; in 19.2% of our cases, minority could not be excluded. This study aspires to further broaden our expertise regarding forensic age estimations. Given the increasing migratory flows, we can expect a notable increase in the frequency of these requests. Consequently, this study aims to promote a multidisciplinary approach and the international standardization of the methodology of these estimations.

Magnetic resonance imaging of knees: a novel approach to predict recombinant human growth hormone therapy response in short-stature children in late puberty

BACKGROUND

There is no appropriate tool to predict recombinant human growth hormone (rhGH) response before therapy initiation in short-stature children in late puberty. The current study aimed to explore the associations between magnetic resonance imaging (MRI) stages of the knee growth plates and rhGH response in short-stature children in late puberty.

METHODS

In this prospective cohort study, short-stature children in late puberty were treated with rhGH and followed up for 6 months. We proposed a novel knee MRI staging system according to the growth plate states of distal femurs or proximal tibias and divided the participants into three groups: unclosed growth plate group, marginally closed growth plate group, and nearly closed growth plate group. The primary outcomes were height gain and growth velocity (GV), which were assessed three months later.

RESULTS

Fifty participants were enrolled, including 23 boys and 27 girls. GV and height gain after 6 months of rhGH therapy decreased successively in the three groups with an increased degree of growth plate fusion, especially when grouped by proximal tibias (GV1-3 mon from 9.38 to 6.08 to 4.56 cm/year, GV4-6 mon from 6.75 to 4.92 to 3.25 cm/year, and height gain from 4.03 to 2.75 to 1.95 cm, all P < 0.001). Moreover, the MRI stages of growth plates independently served as a significant variable for GV and height gain after therapy, especially when grouped by proximal tibias (all P < 0.01).

CONCLUSION

The MRI staging method is expected to be an effective tool for predicting rhGH response before therapy initiation in short-stature children in late puberty.

Radiological age assessment based on clavicle ossification in CT: enhanced accuracy through deep learning

BACKGROUND

Radiological age assessment using reference studies is inherently limited in accuracy due to a finite number of assignable skeletal maturation stages. To overcome this limitation, we present a deep learning approach for continuous age assessment based on clavicle ossification in computed tomography (CT).

METHODS

Thoracic CT scans were retrospectively collected from the picture archiving and communication system. Individuals aged 15.0 to 30.0 years examined in routine clinical practice were included. All scans were automatically cropped around the medial clavicular epiphyseal cartilages. A deep learning model was trained to predict a person's chronological age based on these scans. Performance was evaluated using mean absolute error (MAE). Model performance was compared to an optimistic human reader performance estimate for an established reference study method.

RESULTS

The deep learning model was trained on 4,400 scans of 1,935 patients (training set: mean age = 24.2 years ± 4.0, 1132 female) and evaluated on 300 scans of 300 patients with a balanced age and sex distribution (test set: mean age = 22.5 years ± 4.4, 150 female). Model MAE was 1.65 years, and the highest absolute error was 6.40 years for females and 7.32 years for males. However, performance could be attributed to norm-variants or pathologic disorders. Human reader estimate MAE was 1.84 years and the highest absolute error was 3.40 years for females and 3.78 years for males.

CONCLUSIONS

We present a deep learning approach for continuous age predictions using CT volumes highlighting the medial clavicular epiphyseal cartilage with performance comparable to the human reader estimate.

Postmortem computed tomography assessment of skeletal and dental age in Polish children, adolescents, and young adults

This paper presents a retrospective analysis of postmortem computed tomography (PMCT) scans of secondary ossification centers in the medial clavicular epiphysis, iliac crest apophysis, proximal humeral epiphysis, distal femoral epiphysis, proximal tibial epiphysis, and distal tibial epiphysis. At the same time, we analyzed PMCT scans of the maxillary and mandibular incisors, canines, premolars, and molars. We assessed 203 corpses, whose age ranged from 2 to 30 years, including 156 males and 47 females. The purpose of our study was to compare the processes of secondary ossification center fusion and permanent tooth maturation. Our research hypothesis was that certain stages of skeletal and dental maturation occur along consistent timelines that can be related to the chronological age. Secondary ossification center fusion was evaluated based on Kreitner and also McKern and Steward's classifications. The process of permanent tooth maturation was evaluated with Demirjian's method. Spearman's correlation coefficients (Rho) were positive in all analyses, which indicates that epiphyseal fusion progresses with age. The strongest relationship between the age and the stages of ossification was observed in the proximal tibial epiphysis (p < 0.001; Rho = 0.93) in females and in the medial clavicular epiphysis (p < 0.001; Rho = 0.77) in males. Studies show the importance of concomitant analysis of skeletal and dental maturation with a subsequent comparison of the results to achieve a greater precision in age estimation. A comparison of the results obtained in the study population of Polish children, adolescents, and young adults with the results of other studies in populations of similar ages showed a number of similarities in the time windows of dental and skeletal maturation. These similarities may help in age estimation.

Bone Age Determination of Epiphyseal Fusion at Knee Joint and Its Correlation with Chronological Age

Background and Objectives: Bone age determination is a valuable method for forensic and disaster identifications of unknown human remains, as well as for medical and surgical procedural purposes. This retrospective research study aimed to determine the age based on epiphyseal fusion stages and investigate differences related to gender. Materials and Methods: X-rays of the knee were collected from medical imaging centers in hospitals in the south of Jordan and examined by two observers who determined the bone epiphyseal phase of closure for the femur, tibia, and fibula bone ends close to the knee based on a three-stage classification. Results: The main results revealed that females showed earlier epiphyseal union (Stage II) at the lower end of the femur and the upper ends of the tibia and fibula compared to males. In males, the start of complete union (Stage III) at knee bones was seen at the age of 17-18 years, while in females, it was seen at the age of 16-17 years. Additionally, knee bones showed complete union in 100% of males and females in the age groups 21-22 years and 20-21 years, respectively. Although females showed an earlier start and end of epiphyseal complete union than males, analysis of collected data showed no significant age differences between males and females at the three stages of epiphyseal union of the knee bones. Conclusions: Findings of the radiographic analysis of bone epiphyseal fusion at the knee joint are a helpful method for chronological age determination. This study supports the gender and ethnicity variation among different geographical locations. Studies with a high sample number would be needed to validate our findings.

Age assessment in unaccompanied minors: assessing uniformity of protocols across Europe

Age assessment of migrants is crucial, particularly for unaccompanied foreign minors, a population facing legal, social, and humanitarian challenges. Despite existing guidelines, there is no unified protocol in Europe for age assessment.The Forensic Anthropology Society of Europe (FASE) conducted a comprehensive questionnaire to understand age estimation practices in Europe. The questionnaire had sections focusing on the professional background of respondents, annual assessment numbers, requesting parties and reasons, types of examinations conducted (e.g., physical, radiological), followed protocols, age estimation methods, and questions on how age estimates are reported.The questionnaire's findings reveal extensive engagement of the forensic community in age assessment in the living, emphasizing multidisciplinary approaches. However, there seems to be an incomplete appreciation of AGFAD guidelines. Commonalities exist in examination methodologies and imaging tests. However, discrepancies emerged among respondents regarding sexual maturity assessment and reporting assessment results. Given the increasing importance of age assessment, especially for migrant child protection, the study stresses the need for a unified protocol across European countries. This can only be achieved if EU Member States wholeheartedly embrace the fundamental principles outlined in EU Directives and conduct medical age assessments aligned with recognized standards such as the AGFAD guidelines.

Forensic age estimation of the knee by post-mortem DR, CT, and MR imaging: a comparative study

It is believed by many that reference data for age estimation purposes must be imaging-modality specific. A study from our department has however proven otherwise. We therefore found it interesting to investigate this further by looking at the level of agreement between different imaging modalities. The aim of this study was to investigate the level of agreement between the three radiological modalities, computed tomography (CT), magnetic resonance imaging (MRI), and digital radiography (DR), in assessing the ossification of the epiphyses of the knee. A total of 34 deceased individuals of 10-25 years of age, brought in for a medicolegal autopsy at our department, were scanned by CT, MRI, and DR. The ossification stages of the three bones of the right knee, distal femoral, proximal tibial, and proximal fibular epiphysis were assessed using the established combined staging method by Schmeling et al. and Kellinghaus et al. Analysis of the results by Cohen's weighted kappa showed a good agreement between CT and DR (K = 0.61-0.70), and MRI and DR (K = 0.68-0.79) but only moderate agreement between CT and MRI (K = 0.55-0.57). This leads us to conclude that different radiological images cannot be used interchangeably for age estimation purposes, so reference material needs to be imaging-modality specific. However, to make a more general conclusion research on a larger population is needed.

Automated bone age assessment from knee joint by integrating deep learning and MRI-based radiomics

Bone age assessment (BAA) is a crucial task in clinical, forensic, and athletic fields. Since traditional age estimation methods are suffered from potential radiation damage, this study aimed to develop and evaluate a deep learning radiomics method based on multiparametric knee MRI for noninvasive and automatic BAA. This retrospective study enrolled 598 patients (age range,10.00-29.99 years) who underwent MR examinations of the knee joint (T1/T2*/PD-weighted imaging). Three-dimensional convolutional neural networks (3D CNNs) were trained to extract and fuse multimodal and multiscale MRI radiomic features for age estimation and compared to traditional machine learning models based on hand-crafted features. The age estimation error was greater in individuals aged 25-30 years; thus, this method may not be suitable for individuals over 25 years old. In the test set aged 10-25 years (n = 95), the 3D CNN (a fusion of T1WI, T2*WI, and PDWI) demonstrated the lowest mean absolute error of 1.32 ± 1.01 years, which is higher than that of other MRI modalities and the hand-crafted models. In the classification for 12-, 14-, 16-, and 18- year thresholds, accuracies and the areas under the ROC curves were all over 0.91 and 0.96, which is similar to the manual methods. Visualization of important features showed that 3D CNN estimated age by focusing on the epiphyseal plates. The deep learning radiomics method enables non-invasive and automated BAA from multimodal knee MR images. The use of 3D CNN and MRI-based radiomics has the potential to assist radiologists or medicolegists in age estimation.

Evaluating Skeletal Maturity at Time of Surgical Correction of Pectus Excavatum Based on Medial Clavicle Epiphyseal Ossification

BACKGROUND

Surgical correction of pectus excavatum (SCOPE) is dependent upon chest wall pliability with optimal timing prior to complete skeletal maturation. Measures of skeletal maturity are not readily available for operative planning; therefore, surgeons use age as proxy despite patient-specific rates of skeletal maturation. We aimed to determine whether preoperative skeletal maturity is associated with postoperative pain as surrogate for chest wall pliability.

METHODS

Children ≤18 years who underwent SCOPE from 2020 to 2022 were retrospectively identified. Preoperative CT within 3 months of procedure was reviewed by 2 radiologists and 1 surgeon. Skeletal maturity was determined by Schmeling-Kellinghaus classification which stages secondary epiphyseal ossification of the medial clavicle. Inter-rater reliability was evaluated. Schmeling-Kellinghaus stage and postoperative pain were compared.

RESULTS

Of twenty-eight records reviewed, 57% were Schmeling-Kellinghaus stage 1. High inter-rater reliability was identified (inter-radiologist: kappa = .95, P < .001, all raters: kappa = .78, P < .001). Median age at operation was 15.5 years (interquartile range: 14.8-16.0) and increased with skeletal maturity (P < .001). When comparing stage 1 (n = 16) to >1 (n = 12), stage 1 had lower maximum pain scores (P < .001), total morphine equivalents (P < .001), and benzodiazepine use (P < .001) after surgery.

CONCLUSIONS

The Schmeling-Kellinghaus classification system is a valid proxy of skeletal maturity that can be applied with high inter-rater reliability. SCOPE during stage 1 was found to have less postoperative pain and narcotic use than more mature stages. This is proof of concept that skeletal maturity should be considered when determining optimal timing of surgical correction. Future research will evaluate the impact of skeletal maturity on postoperative outcomes.

Age Estimation Based on Computed Tomography Analysis of the Scapula

Background and Objectives: Age estimation from skeletal remains and in living individuals is an important issue for human identification, and also plays a critical role in judicial proceedings for migrants. Forensic analysis of ossification centers is the main evaluation method for age estimation, and ossification degree can be determined using computed tomography analysis. The purpose of this study is to investigate the applicability of CT (computed tomography) in the analysis of left scapula ossification centers, for forensic age estimation in Turkish society. Materials and Methods: We analyzed six ossification centers of the left scapula and these ossification centers are the coracoid, subcoracoid, coracoid apex, acromial, glenoid, and inferior angle ossification centers. A pediatric radiologist analyzed these six ossification centers of the scapula by using a staging method defined by Schmeling et al. in 2004. Two months after the first assessment, 20 randomly selected cases was reanalyzed by the first observer and by another pediatric radiologist. Correlation between the age and ossification stage was assessed using Spearman's nonparametric correlation test. Linear regression analysis was performed using a backwards model. Cohen's kappa coefficient was used for evaluating interobserver and intraobserver variability. Results: In this retrospective study, 397 (248 male and 149 female) cases were evaluated. Ages ranged between 7.1 and 30.9. The mean age was 19.83 ± 6.49. We determined a positive significant correlation between the age and the ossification stages of ossification centers analyzed in both sexes. In each ossification center, except inferior angle, all of the stage 1 and 2 cases in both sexes were under 18 years old. Intraobserver and interobserver evaluations showed that reproducibility and consistency of the method was relatively good. Conclusions: The present study indicated that CT analysis of scapula ossification centers might be helpful in forensic age assessment of living individuals and dry bones.

Machine learning and deep learning enabled age estimation on medial clavicle CT images

The medial clavicle epiphysis is a crucial indicator for bone age estimation (BAE) after hand maturation. This study aimed to develop machine learning (ML) and deep learning (DL) models for BAE based on medial clavicle CT images and evaluate the performance on normal and variant clavicles. This study retrospectively collected 1049 patients (mean± SD: 22.50±4.34 years) and split them into normal training and test sets, and variant training and test sets. An additional 53 variant clavicles were incorporated into the variant test set. The development stages of normal MCE were used to build a linear model and support vector machine (SVM) for BAE. The CT slices of MCE were automatically segmented and used to train DL models for automated BAE. Comparisons were performed by linear versus ML versus DL, and normal versus variant clavicles. Mean absolute error (MAE) and classification accuracy was the primary parameter of comparison. For BAE, the SVM had the best MAE of 1.73 years, followed by the commonly-used CNNs (1.77-1.93 years), the linear model (1.94 years), and the hybrid neural network CoAt Net (2.01 years). In DL models, SE Net 18 was the best-performing DL model with similar results to SVM in the normal test set and achieved an MAE of 2.08 years in the external variant test. For age classification, all the models exhibit superior performance in the classification of 18-, 20-, 21-, and 22-year thresholds with limited value in the 16-year threshold. Both ML and DL models produce desirable performance in BAE based on medial clavicle CT.

Forensic Diagnostics of the Skeletal Age in the Living - Backgrounds and Methodology

BACKGROUND

The expert opinions on forensic age diagnostics requested by state institutions are used to show the exceeding of legally relevant age thresholds, especially the completed 18th year of life. According to the recommendations of the Study Group on Forensic Age Diagnostics (AGFAD), this requires - among other things - a determination of skeletal age.

METHOD

Considering recent scientific knowledge, the current conditions and established skeletal age diagnostics methods are presented. Additionally, this review article sheds light on the influence of ethnicity and socioeconomic status, questions regarding indication, as well as alternative and future developments.

RESULTS AND CONCLUSION

In forensic age diagnostics, particularly hand radiography and thin-slice CT of the medial clavicular epiphysis are relevant for determining skeletal age. The Atlas method of Greulich and Pyle (1959) and the clavicular stages by Schmeling et al. (2004) and Kellinghaus et al. (2010) are primarily used for this. This spectrum of methods, which is based on a very solid database, might be supplemented by MRI studies of the knee joint in the near future.

KEY POINTS

· Determining skeletal age is an essential part of forensic age diagnostics commissioned by state authorities and courts.. · Hand radiography and CT of the medial clavicular epiphysis form the core of the spectrum of methods recommended by the Study Group of Forensic Age Diagnostics (AGFAD).. · Since the radiological studies required for forensic age diagnostics are not medically indicated, it must be ensured that the legal basis is specifically named in each case when commissioning expert opinions.. · MRI studies of the knee joint might increase the spectrum of methods in the near future..

CITATION FORMAT

· Wittschieber D, Hahnemann ML, Mentzel H. Forensic Diagnostics of the Skeletal Age in the Living - Backgrounds and Methodology. Fortschr Röntgenstr 2024; 196: 254 - 261.

Micro-CT evaluation of morphological degenerative features of sterno-clavicular joint for age-at-death estimation in forensic anthropology - A qualitative analysis

The analysis of the sternoclavicular joint holds significant importance in forensic anthropology, especially through the evaluation of medial clavicular ossification stage, which, however, is helpful only in subjects younger than 30 years of age. Given this limitation, the aim of the present work was to examine, through micro-CT, the surface of sternoclavicular joints of deceased individuals across various age groups, aiming to identify age-related degenerative changes applicable to age estimation in adults over 30 years old. A total of 41 deceased subjects were categorized into three age groups (20-39 years; 40-59 years; ≥60 years) for the analysis. Degenerative morphological features on both clavicular and sternal articular surfaces, including topography, porosity, and presence of osteophytes, were evaluated using a composite scoring system based on a modified "Falys-Prangle method.", which assigns to each parameter specific score ranges: 1-3 for surface topography (smooth, slightly irregular, markedly irregular), 1-6 for porosity (absent, micro- and macroporosity for <50 % or >50 % of surface, surface breakdown), 1-3 for osteophytes (absent, present, not evaluable). The findings revealed a positive correlation between degenerative morphological features and age for both clavicular (rs = 0.719) and sternal articular surfaces (rs = 0.750). Additionally, the combined assessment of the clavicle and sternum, or the evaluation of the clavicle alone, exhibited better differentiation among the three age groups. The micro-CT evaluation of degenerative alterations affecting the sternoclavicular joint proves to be a reliable and efficient method for age estimation in adults.

Comparing a common clavicle maturation-based age estimation method to ordinary regression analyses with quadratic and sex-specific interaction terms in adolescents

Established methods of age estimation are based on correlating defined maturation stages of bony structures with tables representing the observed range of biological ages in the majority of cases. In this retrospective monocentric study in southwestern Germany, common age estimation methodology was assessed in n = 198 subjects at the age of 25 or younger by analyzing the influence of age, quadratic age, biological sex and age-sex interaction on the ossification stages of the medial epiphysis fugue. Three readers (ICC ≥ 0.81 for left/right side) evaluated routine care computed tomography images of the clavicle with a slice thickness of 1 mm. By using least square regression analyses, to determine the real biological age a quadratic function was determined corrected for the age estimated by established methods and sex (R2 = 0.6 each side), reducing the mean absolute error and root mean squared error in the age estimation of women (2.57 and 3.19) and men (2.57 and 3.47) to 1.54 and 1.82 for women, and 1.54 and 2.25 for men. In women, the medial clavicle epiphysis seem to fuse faster, which was particularly observable from approximately 18 years of age. Before that age, the estimation method was relatively close to the ideal correlation between assessed and real age. To conclude, the presented new method enables more precise age estimation in individuals and facilitates the determination and quantification of additional variables, quantifying their influence on the maturation of the medial clavicle epiphysis based on the established ossification stages.

[Epiphysiolysis of the medial clavicle with posterior dislocation : Video article]

OBJECTIVE OF SURGERY

The goal of surgery is the anatomical reduction and stable internal fixation of an epiphysiolysis of the medial clavicle with posterior luxation in a child without harming intrathoracic structures.

INDICATIONS

This case describes an acute epiphysiolysis of the medial clavicle Aitken type 0 with posterior dislocation.

CONTRAINDICATIONS

Soft tissue infections within the region of the surgical access. Allergies against any materials used in the procedure. Successful closed reduction. Additional fracture of the clavicular shaft.

SURGICAL TECHNIQUE

A detailed overview of the surgical technique is available through the video, which is accessible online as well as the graphic overview in this article. Longitudinal incision over the medial clavicle up to the sternoclavicular joint and preparation onto the bony structures. Display of the epiphysiolysis. Reduction of the medial clavicle. Introduction of two Kirscher wires along the longitudinal axis in the direction of the epiphysis and introduction of two sutures. Puncture of the cartilaginous epiphysis with the two sutures. Anatomical reduction of the medial clavicle and fixation by knots. With the continuous use of the sutures, fixation to the anterior periosteum and closure of the periosteum. Wound closure.

FOLLOW-UP

For 6 weeks postoperative limitation of anteversion and abduction to 90°, afterwards unlimited functionality. No routine X‑ray control.

RESULT

After 6 months postoperative the patient is free of pain and has full range of motion. The Constant score is 97/100.

[Validation of method for estimation age of majority by the third molar maturity index on the sample of Ufa population]

The assessment of majority age is important for determining legal responsibility. The definition of the 3rd molar maturity index (Im3) have proven to be a simple and effective method of majority age establishment, the accuracy of which has been tested in different populations. There is a clear lack of studies in this scientific area in Russia.

OBJECTIVE

To test diagnostic accuracy of majority age assessment method by 3rd molar (Cameriere index) in the Ufa sample.

MATERIAL AND METHODS

The number of orthopantomograms equal 120 from males and females aged from 14 to 23 years without apparent pathological changes of the pulp of teeth 38 and 48 was examined. The measures were conducted using the standard R. Cameriere method. The method of logistic regression, determination of predictive values of sensitivity and specificity were used.

RESULTS

The Im3 cut-off point, that was equal 0.08, had a sensitivity of 89% and specificity of 95% in the male sample, accuracy of age group determination was 93%. In the female sample the method sensitivity was 93%, specificity - 97%, accuracy - 97%.

CONCLUSION

The study results confirmed the absence of population variability of the Cameriere index value, that makes it possible to use the majority age determination method by 3rd molar for practical application in the examination of a living person at the territory of the Russian Federation.

Skeletal age estimation of living adolescents and young adults: A pilot study on conventional radiography versus magnetic resonance imaging and staging technique versus atlas method

OBJECTIVE

To compare conventional radiography (CR) and magnetic resonance imaging (MRI) of the left hand/wrist and both clavicles for forensic age estimation of adolescents and young adults.

MATERIALS AND METHODS

CR and MRI were prospectively conducted in 108 healthy Caucasian volunteers (52 males, 56 females) aged 16 to 21 years. Skeletal development was assessed by allocating stages (wrist, clavicles) and atlas standards (hand/wrist). Inter- and intra-observer agreements were quantified using linear weighted Cohen's kappa, and descriptive statistics regarding within-stage/standard age distributions were reported.

RESULTS

Inter- and intra-observer agreements for hand/wrist CR (staging technique: 0.840-0.871 and 0.877-0.897, respectively; atlas method: 0.636-0.947 and 0.853-0.987, respectively) and MRI (staging technique: 0.890-0.932 and 0.897-0.952, respectively; atlas method: 0.854-0.941 and 0.775-0.978, respectively) were rather similar. The CR atlas method was less reproducible than the staging technique. Inter- and intra-observer agreements for clavicle CR (0.590-0.643 and 0.656-0.770, respectively) were lower than those for MRI (0.844-0.852 and 0.866-0.931, respectively). Furthermore, although shifted, wrist CR and MRI within-stage age distribution spread were similar, as were those between staging techniques and atlas methods. The possibility to apply (profound) substages to clavicle MRI rendered a more gradual increase of age distributions with increasing stages, compared to CR.

CONCLUSIONS

For age estimation based on the left hand/wrist and both clavicles, reference data should be considered anatomical structure- and imaging modality-specific. Moreover, CR is adequate for hand/wrist evaluation and a wrist staging technique seems to be more useful than an atlas method. By contrast, MRI is of added value for clavicle evaluation.

Analysis of various radiological age-assessment methods in children, adolescents and young adults regarding the differences between the sexes and sides of the body - A comparative review

A total of 76 articles published within the last twenty years, indexed in the PubMed and ResearchGate databases, were reviewed in order to compare medical imaging-based methods of age estimation of children, adolescents and young adults. The evaluated studies were analyzed for any statistically significant differences between the sexes and sides of the body, sample sizes, and population age. Irrespective of the evaluation method, there were some studies that showed a statistically significant differences in ossification stages between the male and female groups. Most of the studies whose authors conducted a statistical analysis demonstrated no significant differences between the left and right side of the body.

Forensic age estimation with ankle MRI: Evaluating distal tibial and calcaneal epiphyseal fusion

Forensic authorities often request age estimation from forensic experts, particularly in cases related to sexual abuse, child pornography, illegal migration, marriage, etc. The most commonly used method in this regard is radiological methods. Because of the potential dangers of radiation exposure outside of clinical indications, new researches are focusing on non-ionizing and non-invasive technologies. This study aimed to demonstrate the applicability of age estimation in living individuals from ankle magnetic resonance images as a non-ionizing method, and to determine whether it is compatible with individuals' real ages and to establish a database. Ankle MRI images of patients aged between 7 and 26 years who applied to the Cukurova University Faculty of Medicine Balcali Hospital between January 2011 and December 2020 were retrospectively evaluated. A six-stage staging method proposed by Lu et al. was applied to the distal tibial and calcaneal epiphyseal ossification points by examining ankle MRI images of a total of 331 patients, 197 males and 134 females. In the study, images obtained from a sagittal section fast spin echo T1-weighted sequence, with a section thickness of 3-4 mm, were evaluated. As a result of the study, Stage 1 in both distal tibial and calcaneal epiphysis was observed only in patients under 18 years of age in both sex. In males, stage 2 in distal tibial epiphyseal ossification was observed under 18 years of age, except for one case, and stage 5 in both distal tibial and calcaneal epiphyseal ossification was observed in almost all cases over 18 years of age in males. According to the results of our study, magnetic resonance imaging was found to be a non-ionizing method that could be used in addition to other radiological methods aimed at determining the 18-year age limit in age estimation. Multicenter, comparative, and prospective studies conducted by experienced researchers are needed to enable the routine use of MRI in age estimation.

Standards of practice in forensic age estimation with CT of the medial clavicular epiphysis-a systematic review

The AGFAD (Arbeitsgemeinschaft für Forensische Alterdiagnostik, Study Group on Forensic Age Diagnostics) has published several recommendations regarding both technical aspects of computed tomography (CT) of the medial clavicular epiphysis (MCE) and the process of reading and interpreting the CT images for forensic age estimations (FAE). There are, however, no published recommendations regarding CT scan protocols and no dose reference values for CT of the MCE. The objective of this analysis was to assess adherence to AGFAD recommendations among practitioners of FAE and analyse reported dose-relevant CT scan parameters with the objective of helping to establish evidence-based dose reference values for FAE. A systematic literature search was conducted in PubMed and in Google Scholar with specific MeSH terms to identify original research articles on FAE with CT of the MCE from 1997 to 2022. A total of 48 studies were included. Adherence to AGFAD recommendations among practitioners of FAE is high regarding the use of Schmeling main stages (93%), bone window (79%), ≤ 1 mm CT slices (67%), axial/coronal CT images (65%), and Kellinghaus sub-stages (59%). The reporting of CT technique and CT dose-relevant scan parameters is heterogeneous and often incomplete in the current literature. Considering the success achieved by the AGFAD in creating standards of practice of FAE in living subjects, there is potential for the AGFAD to establish standards for radiation protection in FAE as well.

Evaluation of distal tibial epiphysis and calcaneal epiphysis according to the Vieth method in 3.0 T magnetic resonance images: a pilot study

In forensic medicine practice, age estimation-both in living and deceased individuals-can be requested due to legal requirements. Radiologic methods, such as X-rays, for the estimation of bone age have been discussed, and ethical concerns have been raised. Given these factors, radiologic methods that reduce radiation exposure have gained importance and have become one of the research topics in forensic medicine. In this study, the MR images of the ankles of patients aged between 8 and 25 years, obtained with a 3.0 T MR scanner, were evaluated retrospectively according to the staging method defined by Vieth et al. In the study, the ankle MR images of 201 cases (83 females and 118 males) with sagittal T1-weighted turbo spin echo and T2-weighted short tau inversion recovery sequences were evaluated independently by two observers. According to the results of our study, the intra- and inter-observer agreements are at a very good level for both the distal tibial and calcaneal epiphyses. All the cases detected as stages 2, 3, and 4 in both sexes for both the distal tibial and the calcaneal epiphyses have been determined to be under the age of 18 years. According to the data obtained from our study, we consider that stage 5 for males and stage 6 for both sexes in the distal tibial epiphysis and stage 6 for males in the calcaneal epiphysis can be used to estimate the age of 15 years. As far as we know, our study is the first to evaluate ankle MR images with the method defined by Vieth et al. Further studies should be conducted to evaluate the validity of the procedure.

The fusion of ossification centers - A comparative review of radiographic and other imaging modalities of age assessment in living groups of children, adolescents, and young adults

A total of 227 articles published within the last twenty years, indexed in the PUBMED and Researchgate databases, were reviewed for the purpose of comparing medical imaging-based methods of age estimation. The evaluated studies were analyzed in terms of the assessed parts of the body, age, and epiphyseal fusion ages in children, adolescents, and young adults. Our analysis showed that an overwhelming majority of studies had been based on computed tomography and magnetic resonance imaging. A comparison of the studies showed that, irrespective of the imaging modality and the nationality of study population cohorts, the rates of development and the ages at which the process of ossification begins and ends show certain trends.

Evaluation of distal femoral and proximal tibial epiphyseal plate in bone age estimation with 3.0T MRI: a comparison of current methods

OBJECTIVE

Dedouit et al, Kramer et al and Vieth et al defined different staging methods over different sequences in knee MRI for bone age determination. Our study aims to examine three different methods in which the maturation stages of the knee epiphyses are evaluated by MRI in the same population, to compare the methods and results and evaluate them for some age thresholds and to discuss their applicability in forensic age estimation.

METHODS

In this study, 597 knee images obtained using a 3.0T MR scanner were evaluated retrospectively. The T 1 weighted and proton density-weighted sequences were evaluated by two observers. Knee bone development was staged on the femur and tibia, and descriptive statistics were calculated for each stage according to age and sex. Descriptive statistics were presented according to the age and sex of the cases, and intra- and interobserver agreements were evaluated by the κ and κw statistics obtained by the Fleiss approach.

RESULTS

Significant changes were found in stages depending on age. The intra- and interobserver agreement levels were very good (κ > 0.80) for each method. The methods of Dedouit, Kramer and Vieth can be used as an additional criteria for forensic age estimation for 14, 15, 18 and 21 year thresholds.

CONCLUSION

Knee MRI stands out as an alternative modality for age estimation and it is necessary to prefer the method intended for the investigated age range with an individual-specific approach.

ADVANCES IN KNOWLEDGE

Our study stands out as the first study in which current classification methods were applied and compared in the same population for age estimation with knee MRI.

Pediatric age estimation from thoracic and abdominal CT scout views using deep learning

Age assessment is regularly used in clinical routine by pediatric endocrinologists to determine the physical development or maturity of children and adolescents. Our study investigates whether age assessment can be performed using CT scout views from thoracic and abdominal CT scans using a deep neural network. Hence, we retrospectively collected 1949 CT scout views from pediatric patients (acquired between January 2013 and December 2018) to train a deep neural network to predict the chronological age from CT scout views. The network was then evaluated on an independent test set of 502 CT scout views (acquired between January 2019 and July 2020). The trained model showed a mean absolute error of 1.18 ± 1.14 years on the test data set. A one-sided t-test to determine whether the difference between the predicted and actual chronological age was less than 2.0 years was statistically highly significant (p < 0.001). In addition, the correlation coefficient was very high (R = 0.97). In conclusion, the chronological age of pediatric patients can be assessed with high accuracy from CT scout views using a deep neural network.

Automated localization of the medial clavicular epiphyseal cartilages using an object detection network: a step towards deep learning-based forensic age assessment

BACKGROUND

Deep learning is a promising technique to improve radiological age assessment. However, expensive manual annotation by experts poses a bottleneck for creating large datasets to appropriately train deep neural networks. We propose an object detection approach to automatically annotate the medial clavicular epiphyseal cartilages in computed tomography (CT) scans.

METHODS

The sternoclavicular joints were selected as structure-of-interest (SOI) in chest CT scans and served as an easy-to-identify proxy for the actual medial clavicular epiphyseal cartilages. CT slices containing the SOI were manually annotated with bounding boxes around the SOI. All slices in the training set were used to train the object detection network RetinaNet. Afterwards, the network was applied individually to all slices of the test scans for SOI detection. Bounding box and slice position of the detection with the highest classification score were used as the location estimate for the medial clavicular epiphyseal cartilages inside the CT scan.

RESULTS

From 100 CT scans of 82 patients, 29,656 slices were used for training and 30,846 slices from 110 CT scans of 110 different patients for testing the object detection network. The location estimate from the deep learning approach for the SOI was in a correct slice in 97/110 (88%), misplaced by one slice in 5/110 (5%), and missing in 8/110 (7%) test scans. No estimate was misplaced by more than one slice.

CONCLUSIONS

We demonstrated a robust automated approach for annotating the medial clavicular epiphyseal cartilages. This enables training and testing of deep neural networks for age assessment.

[Radiological methods for age diagnostics : Clinical and forensic aspects]

Age diagnostics play an increasing role in radiology. Medical and forensic questions are indications for the application of age diagnostics. In addition to X‑rays of the hand in childhood, panoramic tomography and computed tomography are currently the standard procedures. Alternative modalities without ionizing radiation (sonography, magnetic resonance imaging) have not (yet) been established. The purpose of this article is to present the indications and methods of age diagnostics in the clinical and forensic contexts and to familiarize you with their advantages and disadvantages as well as the possibility of determining the final length.

An Effective Model for Estimating Age in Unaccompanied Minors under the Italian Legal System

This article presents an effective model for estimating the age of subjects without identification documents, in accordance with Italian legislation covering unaccompanied minors, using instrumental methods recognized by the scientific community for age estimation. A decision-making tree has been developed, in which the first step is a physical examination. If secondary sexual characteristics are fully developed and there are no obvious signs of abnormal growth, dental X-rays are the next step. If the roots of the seven left mandibular teeth between the central incisor and the second molar are completely developed, the focus then moves to the third molar. If the index of the third molar (I3M) value is less than 0.08, or if third molars are not assessable, the following step is to study the clavicle which, if fully formed, indicates that the subject is an adult with 99.9% probability; otherwise, the probability is 96%. In all other cases (where the I3M is over 0.08), the probability that the subject has reached 18 years is less than 60%. The research, carried out initially on x-rays of the wrist, teeth and clavicle, highlighted the uselessness of the x-ray of the wrist for determining the age of majority, because in our sample, all subjects with incomplete maturity of hand/wrist bones were under 16 years of age; thus, OPT was necessary anyway. What we propose is a practical, easily feasible, fast, economical, and extremely reliable method, which can be used on Caucasian populations and beyond for multiple forensic purposes.

[Forensic medical examination of the age of living persons in Russia: problematic aspects and solutions]

The article presents the results of the study of quantitative indicators and analytical compilation of forensic medical expert practice data in terms of the age of living persons in Russia examination as a whole and in individual federal districts and subjects of Russia in the period from 2003 to 2021. It has been established that against the background of the rather low number of expert examinations, performed to determine the living persons age, there has been an increase in this indicator since 2018, mainly due to the Central Federal District. Regional differences in the studied indicators were identified. A systematic survey study of literature (electronic search of publications in PubMed, Science Direct Scopus and eLIBRARY databases) was conducted on the issue of forensic medical assessment of living persons' age, including the methodical support of this examination type, to form an idea of existing scientific clusters. Search modes allowed to form an array of 184 publications indexed in the database Scopus, PubMed, and 8 publications presented in Russian Science Citation Index. The study results were used as a predictor of the efficacy of the package of measures to modernize this type of expert study. The proposed set of measures to improve the scientific and methodical support of forensic medical examination for age establishment will optimize practical activities and increase the evidential efficacy of expert opinions.

The distal femoral epiphysis in forensic age diagnostics: studies on the evaluation of the ossification process by means of T1- and PD/T2-weighted magnetic resonance imaging

The age of majority, which corresponds to the age of 18 years in most European countries, plays a crucial role for a large number of legal decisions. Accordingly, an increasing number of requests by authorities to forensic age estimation experts comprise the question of whether the age of 18 years has been reached by an individual. In recent years, novel study data suggested that magnetic resonance imaging (MRI) of the knee might likewise allow for the determination of majority beyond reasonable doubt. However, the data basis, especially concerning the distal femoral epiphysis (DFE), is still poor. For this reason, 392 routine MRI cases of the knee (204 males and 188 females of a Western Caucasian population, aged between 12 and 25 years) were retrospectively analyzed. T1-weighted and water-selective fat-saturated PD/T2-weighted sequences, generated at 1.5 and 3.0 T clinical MR scanners, were available. Ossification stages of the DFE were determined by means of the classification system by Vieth et al. (Eur Radiol 2018; 28:3255-3262). Both the intra-observer agreement and inter-observer agreement were found to be "very good" (κ = 0.899 and κ = 0.830). The present study confirmed that MRI of the DFE is suitable to determine majority in both sexes when stage 6 is present as the study revealed minimum ages above the age of 18 years for this stage (20.40 years in males and 20.60 years in females). Accordingly, the data represent a strong support for the so far existing database. Hence, the investigation of the knee using routine MRI appears to become a realistic alternative for forensic age estimation practice in the near future.

Forensic age estimation in Barcelona: analysis of expert reports issued between 2011 and 2018

INTRODUCTION

In recent years, there has been a notable increase of migratory movements into Europe with the arrival of not (reliably) documented young individuals within EU-Member States. Accordingly, the need for forensic age assessments likewise increased in order to administratively differentiate along the legally relevant cut-off age of 18 completed years. The objective of our study was to analyse the expert reports of forensic age estimation issued in Barcelona between 2011 and 2018.

METHOD

In all cases, data on the medical history, physical examination, radiology of the left hand and orthopantomography were collected. In cases without third molars and a complete ossification of the hand, a CT scan of the clavicles was also performed.

RESULTS

A total of 2754 expert reports were evaluated; 96.7% were males, the majority were of North African origin, mainly from Morocco (63.6%), and 19.6% were sub-Saharan Africans; 65.4% had a level of bone maturation corresponding to the last three standards of Greulich and Pyle. Most cases had mineralization of the third molar corresponding to the F, G or H stages of Demirjian. In 85.9%, there was a correspondence between bone and dental age. A total of 28.8% of the subjects were evaluated as being aged over 18 years; 86.2% of North Africans were considered to be younger than 18, and 82% of sub-Saharan Africans were considered to be over 18 years old.

CONCLUSIONS

In Barcelona, most of the subjects evaluated were male and North African, and 71.2% of the cases were considered to be minors.

Age Estimation in Sportspersons From the Epiphyseal Fusion Around Wrist, Elbow, and Pelvic Joints

Background Age estimation of an individual is an integral part of medicolegal work. Out of many scenarios for which age estimation is performed, competitive sports is the one emerging field where experts are consulted for providing accurate age of the athlete. Owing to the chances of deliberately increasing (padding) or decreasing (shaving) the age of the athlete for his own advantage, accurate age estimation is crucial. The Sports Authority of India (SAI) mandates age verification from experts prior to participation in sports events in various age group categories. One of the widely used methods of age estimation in athletes is the radiological examination of the ossification centers of bones. Methodology The study was performed on 134 athletes (72 males and 62 females) with an age range of 12-18 years old with due permission from the Sports Authority of India (SAI) for this study. These participants compete at state, national, and international levels in squash, handball, swimming, cricket, and judo in under-14, under-16, and under-19 age categories. X-rays of the wrists, elbows, and pelvis were analyzed using the Schmeling five-stage method for the fusion of ossification centers. Results A greater degree of correlation between the fusion stages of all regions of interest and chronological age was observed in males than in females. The highest correlation in both sexes is observed between the fusion score of the head of the radius and the age (R = 0.814 for males and R = 0.647 for females). The lowest correlation for both males and females is seen between the fusion score of the lateral epicondyle of the humerus and age (R = 0.754 for males and R = 0.441 for females). Multiple linear regression models showed a standard error of estimate (SEE) of 1.093 years for the elbow joint, 1.147 years for the wrist joint, 1.039 years for the pelvis joint, and 1.030 years for all three joints. Conclusion Regression models generated for estimating the age of sportspersons from the ossification centers of the elbow, wrist, and pelvis in the present study can be applied for the age estimation of individuals aged between 12 and 18 years. Future population-specific studies on the age estimation of sportspersons with greater sample sizes are necessary to validate the findings of the present study.

Forensic age estimation in males by MRI based on the medial epiphysis of the clavicle

Increasing cross-border migration has brought forensic age assessment into focus in recent decades. Forensic age estimation is based on the three pillars: physical and medical constitution, bone age, and tooth age. Part of the bone age examination includes the assessment of the medial end of the clavicles when the hand bones are already fully developed and a minority must be excluded. Recent research has brought MRI to the forefront as a radiation-free alternative for age assessment. However, there exits only a few studies with large sample size regarding the clavicles and with controversies about staging, motion artifacts, and exclusion based on anatomic norm variants. In the current prospective study, 338 central European male individuals between 13 and 24 years of age underwent MRI examination of the sternoclavicular region. Development was assessed by three blinded raters according to the staging system described by Schmeling et al. and Kellinghaus et al. and related to age by descriptive statistics and transition analyses with a cumulative probit model. In addition, reliability calculations were performed. No statistically significant developmental difference was found between the left and right clavicles. Inter-rater agreement was only moderate, but intra-rater agreement, on the other hand, was good. Stage 3c had a minimum age of 19.36 years and appears to be a good indicator of proof of majority. The minimum age of stage 4 was lower compared with other studies, 20.18 years, and therefore seems not to be an indicator of age of 21 years. In conclusion, we confirmed the value of clavicular MRI in the age estimation process. The transition analysis model is a good approach to circumvent the problems of age mimicry and samples that are not fully equilibrated. Given the moderate agreement between raters, a consensus reading is recommended.

Cartilage Tissue in Forensic Science—State of the Art and Future Research Directions

Cartilage tissue performs many functions in the human body. The diseases and injuries affecting it are prevalent due to its slow regeneration rate. However, cartilage tissue is exceptionally important for its auspicious use in forensic medicine due to its slow postmortem degradation rate. The presented review summarizes the latest research on cartilage tissues and their current and potential applications in forensic science. It also describes the most important studies on using cartilage and its microscopic and macroscopic analyses to estimate the deceased age and determine postmortem interval (PMI) values and the crime weapon. Additionally, the review describes attempts to isolate DNA from cartilage tissue for individual identification. The review also mentions recent, less abundant studies on the cartilage in forensic toxicology and genetics. It points out further directions and prospects for research development on cartilage tissue and its promising use in forensic medicine

Validity of age estimation methods and reproducibility of bone/dental maturity indices for chronological age estimation: a systematic review and meta-analysis of validation studies

Several approaches have been developed to estimate age, an important aspect of forensics and orthodontics, using different measures and radiological examinations. Here, through meta-analysis, we determined the validity of age estimation methods and reproducibility of bone/dental maturity indices used for age estimation. The PubMed and Google Scholar databases were searched to December 31, 2021 for human cross-sectional studies meeting pre-defined PICOS criteria that simultaneously assessed the reproducibility and validity. Meta-estimates of validity (mean error: estimated age-chronological age) and intra- and inter-observer reproducibility (Cohen's kappa, intraclass correlation coefficient) and their predictive intervals (PI) were calculated using mixed-effect models when heterogeneity was high (I2 > 50%). The literature search identified 433 studies, and 23 met the inclusion criteria. The mean error meta-estimate (mixed effects model) was 0.08 years (95% CI - 0.12; 0.29) in males and 0.09 (95% CI - 0.12; 0.30) in females. The PI of each method spanned zero; of nine reported estimation methods, Cameriere's had the smallest (- 0.82; 0.47) and Haavikko's the largest (- 7.24; 4.57) PI. The reproducibility meta-estimate (fixed effects model) was 0.98 (95% CI 0.97; 1.00) for intra- and 0.99 (95% CI 0.98; 1.00) for inter-observer agreement. All methods were valid but with different levels of precision. The intra- and inter-observer reproducibility was high and homogeneous across studies.

Forensische Altersdiagnostik mittels Niederfeld-Magnetresonanztomographie

Hintergrund

Ein rechtlich zulässiges medizinisches Altersfeststellungsverfahren mit möglichst schonenden und zuverlässigen Methoden bei unbegleiteten und fraglich minderjährigen Ausländern ist erforderlich, um den tatsächlich Minderjährigen den für sie gesetzlich vorgesehenen besonderen Schutz zukommen zu lassen.

Ziel der Arbeit

Studiendesign und erste Ergebnisse einer Studie zur forensischen Altersdiagnostik mittels Niederfeld-Magnetresonanztomographie werden vorgestellt.

Material und Methoden

Geplant ist die prospektive Untersuchung von 650 Studienteilnehmenden, gleichmäßig verteilt innerhalb der Altersgruppe 12 bis 24 Jahre zu je 25 Personen je Geschlecht. Es sollen Entwicklungsstadien von distalem Radius, distaler Ulna, distalem Femur und proximaler Tibia mithilfe eines 0,31-Tesla(T)-Niederfeld-MRT-Scanners erfasst und mittels Anwendung der Vieth-Klassifikation ausgewertet werden.

Ergebnisse

Nach Auswertung der Untersuchungen der bisher 487 untersuchten Studienteilnehmenden ist ersichtlich, dass die gewählten Sequenzen die für die Vieth-Klassifikation relevanten Charakteristika der Ossifikation der untersuchten Epiphysen erfassen. Die Untersuchungen erweisen sich überdies als einfach in der Durchführung.

Schlussfolgerung

Untersuchungen zur forensischen Altersschätzung am Lebenden unter Anwendung der Vieth-Klassifikation sind mit Niederfeld-MRT-Scannern bei einer Feldstärke von 0,31 T durchführbar. Es bleibt zu klären, ob die mit einem 0,31-T-Niederfeld-MRT-Scanner nachweisbaren Ossifikationsmerkmale am Handgelenk und am Knie einen zweifelsfreien Volljährigkeitsnachweis erlauben.