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Li Y, Wei S, Canavese F, Liu Y, Li J, Liu Y, Xu H. Treatment and Outcome of Supracondylar Humeral Fractures in Children Over 10 Years of Age at the Time of Injury: A Review of 60 Cases. J Pediatr Orthop 2024; 44:e580-e587. [PMID: 38676464 DOI: 10.1097/bpo.0000000000002710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
OBJECTIVES To assess the treatment and outcomes of supracondylar humeral fractures (SHFs) in children older than 10 years of age at the time of injury. METHODS The study analyzed clinical data from 60 patients who sustained SHF, all over the age of 10 years, were analyzed. The patients included 49 males and 11 females with a mean age of 10.9 ± 0.9 years (range, 10 to 14.5). All patients underwent surgical treatment under general anesthesia. Closed reduction (CR) and percutaneous fixation were the primary treatment, with open reduction and internal fixation being employed only in cases CR was unsuccessful. The study assessed the healing of fractures by measuring the radiographic angles, including the carrying angle (RCA), Baumann's angle (BA), and metaphyseal-diaphyseal angle (MDA) on anteroposterior radiographs of the elbow joint. In addition, the study evaluated whether the anterior humeral line (AHL) appropriately passed through the middle third of the capitellum. The final follow-up visit used the Mayo Elbow Performance Index score (MEPI) and Flynn's criteria to analyze the recovery of elbow function. RESULTS There were 15 (25%) SHF type II, 17 (28.3%) type III and 28 (46.7%) type IV. Of the 60 patients, 56 (93.3%) underwent successful CR, whereas 4 (6.7%) required open reduction and internal fixation because of an unsuccessful CR. The final follow-up showed the average BA as 72° ± 5.3°, the average MDA as 88.3° ± 2.8°, and the average RCA as 9.6° ± 3.9°. The AHL bisected accurately the capitellum in 59 cases (98.3%). The average range of elbow flexion-extension was 146.6° ± 8.6°, whereas the average MEPI score was 99.9 ± 0.6; 98.3% (n=59) were rated as excellent and 1.7% (n=1) were rated as good. According to Flynn's criteria, 86.7% had an excellent outcome (n=52), 10% had a good outcome (n=6), and 3.3% had a poor outcome (n=2). Only 1 patient (1.7%) experienced redisplacement. Eight cases of nerve injury were reported, with 7 involving the radial nerve and 1 involving the ulnar nerve; all resolved spontaneously. CONCLUSIONS CR and percutaneous fixation have been shown to be effective in treating SHF in 93.3% of children aged 10 years old and older at the time of injury, with favorable radiographic and functional outcomes and a low risk of secondary displacement. Open reduction should only be considered when CR is ineffective.
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Affiliation(s)
- YiQiang Li
- Department of Pediatric Orthopedics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Sheng Wei
- Department of Pediatric Orthopedics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Federico Canavese
- Department of Pediatric Orthopedics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Pediatric Orthopedic Surgery, Jeanne de Flandre Hospital, Lille University Centre, Lille, France
| | - YuanZhong Liu
- Department of Pediatric Orthopedics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - JingChun Li
- Department of Pediatric Orthopedics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - YanHan Liu
- Department of Pediatric Orthopedics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - HongWen Xu
- Department of Pediatric Orthopedics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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Liu T, Jie Q, Wang E, Li L, Canavese F. Editorial: Elbow injury in pediatric patients. Front Pediatr 2023; 11:1228234. [PMID: 37425265 PMCID: PMC10325645 DOI: 10.3389/fped.2023.1228234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/16/2023] [Indexed: 07/11/2023] Open
Affiliation(s)
- Tianjing Liu
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang City, China
| | - Qiang Jie
- Department of Pediatric Orthopedics, Xi’an Honghui Hospital, Xi'an, China
| | - Enbo Wang
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang City, China
| | - Lianyong Li
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang City, China
| | - Federico Canavese
- Department of Pediatric Orthopedics, Lille University Center - Jeanne de Flandre Hospital, Lille, France
- Faculty of Medicine, Nord-de-France Lille University, Lille, France
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Yang D, Kell D, Syed A, Huang K, Sarkar S, Goodbody CM, Williams BA. Does Skeletal Maturity Predict the Pattern of Tibial Tubercle Avulsion Fracture? J Pediatr Orthop 2023; Publish Ahead of Print:01241398-990000000-00286. [PMID: 37205835 DOI: 10.1097/bpo.0000000000002435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND Proximal tibial physeal development and closure is thought to relate to tibial tubercle avulsion fracture (TTAF) patterns. Prior work has yet to formally evaluate the relationship between skeletal maturity and fracture pattern. Using 2 knee radiograph-derived skeletal maturity assessments [growth remaining percentage (GRP) and epiphyseal union stage], we examined their association with TTAF injury patterns using the Ogden and Pandya fracture classifications. We hypothesized that different TTAF injuries would occur during unique periods of skeletal development. METHODS Pediatric patients sustaining TTAFs treated at a single institution (2008-2022) were identified using diagnostic and procedural coding. Demographics and injury characteristics were collected. Radiographs were reviewed to assign epiphyseal union stage, Ogden and Pandya classifications and for measurements to calculate GRP. Univariate analyses examined the relationship between injury subgroups, patient demographics, and skeletal maturity assessments. RESULTS Inclusion criteria identified 173 patients with a mean age of 14.76 (SD: 1.78) and 2.95% (SD: 4.46%) of growth remaining. The majority of injuries were classified Ogden III/Pandya C. Most (54.9%) were the result of the axial loading mechanism. Ogden groups showed no significant differences across all patient characteristics studied including age and GRP. With the exception of Pandya A fractures, we did not identify a direct relationship between GRP, age, and Pandya groups. Epiphyseal union stage differed for Pandya A and D groups. CONCLUSIONS A predictable pattern in TTAF characteristics across skeletal (GRP), epiphyseal union, or chronologic age was not identified in this study. Distal apophyseal avulsions (Ogden I/II and Pandya A/D) occurred across a broad chronologic and skeletal age range. No differences were identified in epiphyseal or posterior extension (Ogden III/IV and Pandya B/C) injuries. Although differences in age and GRP were identified among Pandya As, this is thought to be due to the degree of skeletal immaturity that is a prerequisite for differentiation from Pandya Ds. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Affiliation(s)
- Daniel Yang
- Department of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA
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The Dimeglio Olecranon Method Is Reliable in Diverse, Contemporary Patients for Predicting Future Growth. J Pediatr Orthop 2023; 43:e249-e253. [PMID: 36729614 DOI: 10.1097/bpo.0000000000002328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Growth assessment, which relies on a combination of radiographic and clinical markers, is an integral part of clinical decision-making in pediatric orthopaedics. The aim of this study is to evaluate the accuracy and reliability of the Diméglio skeletal age system using a modern cohort of pediatric patients. METHODS A retrospective review was undertaken of all patients at a large tertiary pediatric hospital who had lateral forearm radiographs (before the age of 14 y for females and before 16 y for males). In addition, all of these patients had height measurements within 60 days of their forearm x-ray and a final height listed in their medical records. The x-rays were graded by 5 reviewers according to the Diméglio skeletal age system. Inter and intraobserver reliability was tested. RESULTS One hundred forty-seven patients with complete radiographs and height data were evaluated by 5 observers ranging in experience from medical students to senior pediatric orthopaedic surgeons. The Diméglio system demonstrated excellent reliability across levels of training with an intraobserver correlation coefficient of 0.995 (95% CI, 0.991-0.997) and an interobserver correlation coefficient of 0.906 (95% CI, 0.857-0.943). When the Diméglio stage was paired with age and sex in a multivariable linear regression model predicting the percent of final height, the adjusted R2 was 78.7% (model P value <0.001), suggesting a strong relationship between the Diméglio stage (plus age and sex) and percent of final height. CONCLUSION This unique approach to maturity assessment demonstrates that the Diméglio staging system can be used effectively in a modern, diverse patient population. LEVEL OF EVIDENCE Level II; retrospective cohort study.
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Lee SY, Im SA. Comparison of Bone Agesin Early Puberty: Computerized Greulich-Pyle Based Bone Age vs. Sauvegrain Method. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2022; 83:1081-1089. [PMID: 36276197 PMCID: PMC9574274 DOI: 10.3348/jksr.2021.0128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/19/2021] [Accepted: 11/22/2021] [Indexed: 11/21/2022]
Abstract
Purpose To compare the computerized Greulich-Pyle based bone age with elbow bone age. Materials and Methods A total of 2126 patients (1525 girls; 601 boys) whose elbow bone age was within the evaluable range by the Sauvegrain method, and who simultaneously underwent hand radiography, were enrolled in the study. The 1st-bone age and VUNO score of the hand were evaluated using VUNOMed-BoneAge software. The correlation between the hand and elbow bone age was analyzed according to the child's gender and the probability of 1st-bone age. Results The correlation between VUNO score and elbow bone age (r = 0.898) was higher than the correlation between 1st-bone age and elbow bone age (r = 0.879). Moreover, the VUNO score showed a better correlation with the elbow bone age in patients with a 1st-bone age probability of less than 70%, or in girls. Elbow bone age was more advanced compared to hand bone age, and this difference increased until the middle of puberty and gradually decreased in the latter half. Conclusion The computerized Greulich-Pyle based hand bone age showed a significant correlation with the elbow bone age at puberty. However, since the elbow bone age tends to advance faster than the hand bone age, caution is required while judging the bone age during puberty.
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The status of forensic radiography in the Nordic Countries: Results from the 2020 IAFR questionnaire. FORENSIC IMAGING 2022. [DOI: 10.1016/j.fri.2022.200502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jang WY, Ahn KS, Oh S, Lee JE, Choi J, Kang CH, Kang WY, Hong SJ, Shim E, Kim BH, Je BK, Jung HW, Lee SH. Difference between bone age at the hand and elbow at the onset of puberty. Medicine (Baltimore) 2022; 101:e28516. [PMID: 35029913 PMCID: PMC8735777 DOI: 10.1097/md.0000000000028516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/17/2021] [Indexed: 11/25/2022] Open
Abstract
In the pubertal period, bone age advances rapidly in conjunction with growth spurts. Precise bone-age assessments in this period are important, but results from the hand and elbow can be different. We aimed to compare the bone age between the hand and elbow around puberty onset and to elucidate the chronological age confirming puberty onset according to elbow-based bone age.A total of 211 peripubertal subjects (127 boys and 84 girls) who underwent hand and elbow radiographs within 2 months was enrolled. Two radiologists and a pediatric orthopedic surgeon assessed bone age. Hand bone age was graded using the Greulich-Pyle (GP) method, and elbow bone age was determined using the Sauvegrain method. The correlation of 2 methods was evaluated by Demining regression analysis, and the mean absolute difference (MAD) with chronological age was compared between pre-pubertal and pubertal subjects. Receiver-operating characteristic curve analysis was performed to determine the chronological age confirming puberty onset.There was a statistically significant difference in bone age revealed by the GP and Sauvegrain methods in the pubertal group. In the pubertal group, the MAD was 1.26 ± 0.90 years with the GP method and 0.61 ± 0.47 years with the Sauvegrain method in boys (P < .001), while in girls, the MAD was 0.84 ± 0.60 years and 0.53 ± 0.36 years with the same 2 methods (P = .033). The chronological age for confirming puberty onset using the elbow was 12.2 years in boys and 10.3 years in girls.The bone ages of hand and elbow were different at puberty, and the elbow was a more reliable location for bone-age assessment at puberty. Puberty onset according to elbow occurred slightly earlier than expected.
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Affiliation(s)
- Woo Young Jang
- Department of Orthopedic Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Kyung-Sik Ahn
- Department of Radiology, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Saelin Oh
- Department of Radiology, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Ji Eun Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jimi Choi
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Chang Ho Kang
- Department of Radiology, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Woo Young Kang
- Department of Radiology, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Suk-Joo Hong
- Department of Radiology, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Eddeum Shim
- Department of Radiology, Korea University Ansan Hospital, Gyeonggi-do, Republic of Korea
| | - Baek Hyun Kim
- Department of Radiology, Korea University Ansan Hospital, Gyeonggi-do, Republic of Korea
| | - Bo-Kyung Je
- Department of Radiology, Korea University Ansan Hospital, Gyeonggi-do, Republic of Korea
| | - Hae Woon Jung
- Department of Pediatrics, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Soon Hyuck Lee
- Department of Orthopedic Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
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Greene JD, Yu K, Li DT, Furdock RJ, Li E, Liu RW, Cooperman DR. The Relationship of Olecranon Apophyseal Ossification and Sanders Hand Scores with the Timing of Peak Height Velocity in Adolescents. J Bone Joint Surg Am 2021; 103:1543-1551. [PMID: 33974573 DOI: 10.2106/jbjs.20.01856] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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 Diméglio 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.
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Affiliation(s)
- Janelle D Greene
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Kristin Yu
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Don T Li
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Ryan J Furdock
- Department of Orthopaedics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Eric Li
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Raymond W Liu
- Department of Orthopaedics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Daniel R Cooperman
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
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Cheung PWH, Canavese F, Luk KDK, Cheung JPY. An insight of how multiple skeletal maturity indices can be used for growth assessment: relationship between the simplified olecranon, simplified digital, and distal radius and ulna classifications. J Pediatr Orthop B 2021; 30:371-380. [PMID: 32649422 PMCID: PMC8154180 DOI: 10.1097/bpb.0000000000000760] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
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 < 0.001). Mapping revealed uneven spans and coverage of different periods by each index. Olecranon stage 1 coincided with R3 (for girls), R4 (for boys), U3, and SS1. Olecranon stage 5 occurred as early as R7, U6, and SS4. Upon elbow fusion, the simplified digital (SS5-SS8) and DRU (R8-R11 and U7-U9) classifications can be used for assessment until maturity. The inter-relationship of the simplified hand, wrist, and olecranon methods indicates their combined use. DRU grades can be used in growth periods which are less well covered. Prepubertal and growth acceleration phase of pubertal growth spurt can best be assessed by both the simplified olecranon (stages 1-3) and DRU classifications (R1-R5 and U1-U4). All three indices are required during PHV. For post-PHV, DRU (R8-R11 and U7-U9) and simplified digital method (SS5-SS8) complement each other for assessment until skeletal maturity.
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Affiliation(s)
- Prudence Wing Hang Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Federico Canavese
- Department of Pediatric Surgery, University Hospital Estaing, Clermont-Ferrand, France
| | - Keith Dip Kei Luk
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Jason Pui Yin Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
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Alijani S, Farhadian N, Alafchi B, Najafi M. Relationship of Frontal Sinus Size and Maturation of Cervical Vertebrae for Assessment of Skeletal Maturity. Front Dent 2021; 17:1-6. [PMID: 33615297 PMCID: PMC7883657 DOI: 10.18502/fid.v17i20.4314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 07/17/2020] [Indexed: 11/24/2022] Open
Abstract
Objectives: This study aimed to assess the relationship of frontal sinus height and width with the cervical vertebral maturation (CVM) for assessment of skeletal maturity. Materials and Methods: This retrospective study evaluated lateral cephalograms of 132 patients between 8 to 21 years, including 66 males and 66 females. For each of the six stages of the CVM, 22 patients (11 males and 11 females) were evaluated. The Ertuk’s method was used to measure the height and width of the frontal sinus. The sinus height to width ratio was calculated and considered as the sinus index. The CVM was evaluated on the same lateral cephalograms using the Baccetti’s method. The correlation of frontal sinus height and width with the CVM was analyzed, and comparisons were made using independent t-test, ANOVA, Mann-Whitney test, and Kendall’s tau-b correlation coefficient. Results: The sinus width was 10.85±2.7 mm in males and 9.47±2.6 mm in females. The sinus index was 2.43±0.37 in males and 2.66±0.32 in females (P<0.000). The frontal sinus index and width were significantly greater in males but the sinus length was not significantly different between males and females (P=0.383). Significant differences were found in stages 2 and 3, and also 4 and 5 in females and 2 and 3, 3 and 4, and 4 and 5 in males. The mean frontal sinus index had a significant correlation with the CVM stage in both groups. Conclusion: According to the results, the frontal sinus index cannot be used as a predictor of skeletal maturity.
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Affiliation(s)
- Sara Alijani
- Orthodontics Department, Dental Faculty, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Nasrin Farhadian
- Orthodontics Department, Dental Faculty, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Behnaz Alafchi
- Department of Biostatistics, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mahsa Najafi
- Orthodontics Department, Dental Faculty, Hamadan University of Medical Sciences, Hamadan, Iran
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Abstract
BACKGROUND The creation of accurate markers for skeletal maturity has been of significant interest to orthopaedic surgeons. They guide the management of diverse disorders such as adolescent idiopathic scoliosis, leg length discrepancy, cruciate ligament injuries, and slipped capital femoral epiphysis. Multiple systems have been described to predict growth using radiographic skeletal markers; however, no such system has yet been developed for the proximal tibia. The purpose of this study was to establish quantitative radiographic parameters within the proximal tibia that can be used to assess degree of skeletal maturity. METHODS From the Bolton Brush collection, 94 children, consisting of 49 girls and 4 boys between the ages of 3 and 18 years old, were followed annually throughout growth with serial radiographs and physical examinations. Final height at maturity was used to calculate the growth remaining at each visit. Multiple measurements for each knee radiograph were performed and correlated with the percentage of growth remaining. Tibial epiphysis width, tibial metaphysis width, and height of the lateral tibial epiphysis were measured on each film and the composite ratios between each of these sets of variables along with their respective accuracy and reliability were calculated. Single and multiple linear regression models were constructed to determine accuracy of prediction. Interobserver and intraobserver studies were performed with 4 investigators ranging from medical student to senior attending and calculated using the intraclass correlation coefficient. All 4 examiners measured all of the subjects and the ratios created were averaged. RESULTS Tibial epiphysis width, tibial metaphysis width, and height of the lateral tibial epiphysis were all found to be strongly correlated with growth remaining with R values ranging from 0.57 to 0.84. In addition, all 3 ratios were found to be reliable with intraobserver and interobserver intraclass correlation coefficients ranging from 0.92 to 0.94 and 0.80 to 0.94, respectively. A multiple linear regression model demonstrated that combining these 3 ratios allows for a predictive R value of 0.917, showing that these ratios when combined were highly predictive of growth remaining. All findings were independent of sex (P=0.996). CONCLUSIONS We describe 3 measurements that can easily be obtained on an anteroposterior radiograph of the knee. We demonstrate that ratios of these variables can be measured reliably and correlate closely with remaining growth, independent of sex. Together, we believe that these factors will improve the accuracy of determining growth from lower extremity radiographs that include the proximal tibia. CLINICAL RELEVANCE This study provides a new quantitative technique to evaluate growth in the lower extremity, which can inform a range of conditions including adolescent idiopathic scoliosis, leg length discrepancy, cruciate ligament injury, and slipped capital femoral epiphyses.
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Gupta N, Lustig RH, Andrews H, Sylvester F, Keljo D, Goyal A, Gokhale R, Patel AS, Guthery S, Leu CS. Introduction to and Screening Visit Results of the Multicenter Pediatric Crohn's Disease Growth Study. Inflamm Bowel Dis 2020; 26:1945-1950. [PMID: 32190893 PMCID: PMC7676423 DOI: 10.1093/ibd/izaa023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Statural growth impairment is more common in males with Crohn's disease (CD). We assessed sex differences in height Z score differences and bone age (BA) Z scores and characterized age of menarche in a novel contemporary cohort of pediatric CD patients undergoing screening for enrollment in the multicenter longitudinal Growth Study. METHODS Crohn's disease patients (females with chronological age [CA] 5 years and older and younger than 14 years; males with CA 6 years and older and younger than 16 years) participated in a screening visit for the Growth Study. Height BA-Z scores are height Z scores calculated based on BA. Height CA-Z scores are height Z scores calculated based on CA. The height Z score difference equals height CA-Z score minus height BA-Z score. RESULTS One hundred seventy-one patients (60% male) qualified for this analysis. Mean CA was 12.2 years. Mean height CA-Z score was -0.4, and mean height BA-Z score was 0.4 in females. Mean height CA-Z score was -0.1, and mean height BA-Z score was 0.2 in males. The absolute value of the mean height Z score difference was significantly greater in females (0.8) than males (0.3; P = 0.005). The mean BA-Z score in females (-1.0) was significantly lower than in males (-0.2; P = 0.002). The median CA at menarche was 13.6 (95% CI, 12.6-14.6) years. CONCLUSIONS Our screening visit data suggest that standardized height gain is lower in males with skeletal maturation and delayed puberty is common in females in CD. We are investigating these findings in the ongoing Growth Study.
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Affiliation(s)
- Neera Gupta
- Department of Pediatrics, Weill Cornell Medicine, New York, NY,Address correspondence to: Neera Gupta, MD, MAS, Division of Gastroenterology and Nutrition, Department of Pediatrics, Weill Cornell Medicine, 505 East 70th Street, Helmsley Tower, 3rd Floor, New York, NY 10021, USA. E-mail:
| | - Robert H Lustig
- Division of Endocrinology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Howard Andrews
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York City, NY
| | - Francisco Sylvester
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David Keljo
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Alka Goyal
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Mercy Kansas City, Kansas City, MI
| | - Ranjana Gokhale
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Chicago Comer Children’s Hospital, Chicago, IL
| | - Ashish S Patel
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX
| | - Stephen Guthery
- Division of Gastroenterology, Hepatology, and Nutrition, Primary Children’s Hospital and the University of Utah, Salt Lake City, UT
| | - Cheng-Shiun Leu
- Department of Biostatistics, Columbia University Medical Center, New York City, NY
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Evaluation of Skeletal Maturity Using the Distal Femoral Physeal Central Peak Is Not Significantly Affected by Radiographic Projection. J Pediatr Orthop 2020; 39:e782-e786. [PMID: 30649084 DOI: 10.1097/bpo.0000000000001340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Accurate estimation of skeletal maturity is important in several pediatric orthopaedic conditions. The current gold standard for estimating skeletal maturity using the Greulich and Pyle Bone Atlas is complex and shown to have significant interobserver variability. Recent data have shown peak height velocity to occur on average at 90% of final adult height, providing an improved gold standard to quantify skeletal maturity, facilitating the investigation of different skeletal maturity systems. Measurement of topographical changes to the developing distal femoral physis on anteroposterior (AP) radiographs allow for calculation of the central peak value (CPV), a quantitative method shown to provide accurate prediction of 90% of final adult height. The purpose of this study was to assess the clinical tolerance of the CPV method to varying beam angles by comparing measurement reliability between AP radiographs of the knee versus standing hip-to-ankle leg-length radiographs. METHODS We searched our institution's pediatric orthopaedic clinical database for skeletally immature patients evaluated with both standard AP radiographs of the knee as well as standing hip-to-ankle radiographs. Patients included female individuals aged 7 to 16 years and male individuals aged 7 to 18 years with both radiographs within 6 months. CPV was measured using a previously published method. Intraclass correlation coefficient was calculated to determine the level of agreement between observers in all available radiographs. CPVs between AP radiographs of the knee and standing hip-to-ankle radiographs were compared using a paired t test to determine if there is a significant difference between radiographic projection and sex. RESULTS A total of 78 subjects meeting appropriate inclusion and exclusion criteria were identified. intraclass correlation coefficient value was 0.873, indicating excellent interobserver reliability for CPV measurements. The mean time between radiographs was 0.30 years for male and 0.27 years for female patients. CPV values between the 2 radiographic projections were not significantly different in male (P=0.37), female (P=0.22) or male+female patients (P=0.17). CPV values were significantly higher in male patients on both AP radiographs (P<0.001) and standing hip-to-ankle radiographs (P<0.001) when compared with female patients. CONCLUSIONS The CPV is a quick, quantitative method for estimating skeletal maturity. CPVs are not significantly different between standard AP radiographs of the knee versus standing hip-to-ankle leg-length radiographs, expanding the potential to utilize this method without the need for additional expense or radiation. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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Dimeglio A, Canavese F. The immature spine: growth and idiopathic scoliosis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:22. [PMID: 32055613 PMCID: PMC6995907 DOI: 10.21037/atm.2019.11.134] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/22/2019] [Indexed: 12/29/2022]
Abstract
Untreated progressive scoliosis can have negative effects on the growing spine as asymmetrical forces will act on the growth plates of the vertebral column (>130 growth plates). Spinal growth can be considered as a mixture of hierarchy, synchronization, and harmony: the slightest error can lead to a complex malformation; it is also a very dynamic process although it does not progress linearly: periods of acceleration are followed by periods of deceleration. Remaining growth is a determining factor for the worsening of idiopathic scoliosis (IS): the younger is the child, the higher is the risk of progression, and the more severe will be the disease. After birth, growth of the spine is not linear, and three periods can be identified: (I) between birth and age 5 years; (II) between age 5 and 10 years of age; (III) between age 10 and skeletal maturity. Spine and thoracic cage growth are correlated, although their growth is not synchronous. Timely control of the spinal deformity and its correction are mandatory to restore-as soon as possible-the harmony and the hierarchy of growth between the different growth plates. If action is delayed, the abnormal growth and the subsequent anatomical modifications will lead to a progressive, evolutive, and irreversible clinical picture. This article aims to provide a comprehensive review of how spinal deformities can affect the normal spine and thoracic cage growth.
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Affiliation(s)
- Alain Dimeglio
- Pediatric Orthopedic Department, Clinique St. Roch, Montpellier, France
| | - Federico Canavese
- Pediatric Surgery Department, University Hospital Estaing, Clermont-Ferrand, France
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Sinthuprasith P, Dejkhamron P, Wejaphikul K, Unachak K. Near final adult height, and body mass index in overweight/obese and normal-weight children with idiopathic central precocious puberty and treated with gonadotropin-releasing hormone analogs. J Pediatr Endocrinol Metab 2019; 32:1369-1375. [PMID: 31605579 DOI: 10.1515/jpem-2019-0136] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 08/28/2019] [Indexed: 12/17/2022]
Abstract
Background The standard treatment of central precocious puberty (CPP) is gonadotropin-releasing hormone analogues (GnRHa). It is a concern that children treated with GnRHa are at risk of developing obesity which could impair the treatment outcomes. This study aimed to investigate the effect of GnRHa on body mass index (BMI) standard deviation score (SDS), and the influence of BMI status on treatment outcomes in children with idiopathic CPP (iCPP). Methods A retrospective cohort study in children with iCPP who completed GnRHa treatment and had attained near final adult height (NFAH) was conducted. Children with a history of disease or drug ingestion which could affect their BMI were excluded. BMI, BMI SDS, height (Ht), Ht SDS, predicted adult height (PAH), and NFAH were compared at baseline, 1 and 2 years during treatment, and at NFAH according to the baseline BMI status; normal weight and overweight/obesity. Results Fifty-eight children with iCPP treated with GnRHa were enrolled. The BMI SDS was significantly increased at 1 and 2 years during treatment in the overweight/obese group and at 1 year during treatment in the normal-weight group. However, at NFAH (2 years after treatment discontinuation), the BMI SDS was not statistically different from baseline in both groups. Ht gain, change in Ht SDS and BMI SDS were not statistically different from the baseline in both groups. Conclusions GnRHa results in a transient increase in BMI SDS during treatment and returned to baseline after treatment cessation. The benefit of GnRHa treatment on final Ht improvement is similar between overweight/obese and normal-weight patients.
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Affiliation(s)
| | - Prapai Dejkhamron
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand, Phone: +66-53-93-6462, Fax: +66-53-93-6461
| | - Karn Wejaphikul
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kevalee Unachak
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Alberghina F, Andreacchio A, Canavese F. Current concepts on humeral intercondylar fractures in children and adolescents. MINERVA ORTOPEDICA E TRAUMATOLOGICA 2019; 70. [DOI: 10.23736/s0394-3410.19.03901-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
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Abstract
Spinal fusion in young children for treatment of early onset scoliosis is not optimal because it limits growth and contributes to long-term lung compromise. Various types of growth-friendly spinal implants and newer technologies have been introduced in the past few years. Similarly, in adolescent idiopathic scoliosis, fusion decreases spinal mobility and may lead to development of adjacent level disc degeneration. A variety of different new technologies have been developed for alternative surgical approaches that halt curve progression while maintaining spinal mobility.
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Affiliation(s)
- Yasser Ibrahim Alkhalife
- Division of Orthopaedic Surgery, IWK Health Centre, PO Box 9700, 5850 University Avenue, Halifax, Nova Scotia, B3K-6R8 Canada
| | - Kedar Prashant Padhye
- Division of Orthopaedic Surgery, IWK Health Centre, PO Box 9700, 5850 University Avenue, Halifax, Nova Scotia, B3K-6R8 Canada
| | - Ron El-Hawary
- Division of Orthopaedic Surgery, IWK Health Centre, PO Box 9700, 5850 University Avenue, Halifax, Nova Scotia, B3K-6R8 Canada.
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Knapik DM, Sanders JO, Gilmore A, Weber DR, Cooperman DR, Liu RW. A quantitative method for the radiological assessment of skeletal maturity using the distal femur. Bone Joint J 2018; 100-B:1106-1111. [PMID: 30062944 DOI: 10.1302/0301-620x.100b8.bjj-2017-1489.r1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Aims Using 90% of final height as a benchmark, we sought to develop a quick, quantitative and reproducible method of estimating skeletal maturity based on topographical changes in the distal femoral physis. Patients and Methods Serial radiographs of the distal femoral physis three years prior to, during, and two years following the chronological age associated with 90% of final height were analyzed in 81 healthy children. The distance from the tip of the central peak of the distal femoral physis to a line drawn across the physis was normalized to the physeal width. Results A total of 389 radiographs of the distal femur with corresponding Greulich and Pyle bone ages and known chronological ages were measured. Children reached 90% of final height at a mean age of 11.3 years (sd 0.8) for girls and 13.2 years (sd 0.6) for boys. Linear regression analysis showed higher correlation coefficent in predicting the true age at 90% of final height using chronological age + gender + central peak value (R2 = 0.900) than chronological age + gender (R2 = 0.879) and Greulich and Pyle bone age + gender (R2 = 0.878). Conclusion Chronological age + gender + central peak value provides more accurate prediction of 90% of final height compared with chronological age + gender and Greulich and Pyle bone age + gender. Cite this article: Bone Joint J 2018;100-B:1106-11.
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Affiliation(s)
- D M Knapik
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA and Rainbow Babies and Children's Hospital at Case Western Reserve University, Cleveland, Ohio, USA
| | - J O Sanders
- University of Rochester, Rochester, New York, USA
| | - A Gilmore
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA and Rainbow Babies and Children's Hospital at Case Western Reserve University, Cleveland, Ohio, USA
| | - D R Weber
- Division of Endocrinology and Diabetes, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - D R Cooperman
- Department of Orthopaedics and Rehabilitation, Yale University, New Haven, Connecticut, USA
| | - R W Liu
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA and Rainbow Babies and Children's Hospital at Case Western Reserve University, Cleveland, Ohio, USA
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Rosas A, Ríos L, Estalrrich A, Liversidge H, García-Tabernero A, Huguet R, Cardoso H, Bastir M, Lalueza-Fox C, de la Rasilla M, Dean C. The growth pattern of Neandertals, reconstructed from a juvenile skeleton from El Sidrón (Spain). Science 2018; 357:1282-1287. [PMID: 28935804 DOI: 10.1126/science.aan6463] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 07/27/2017] [Indexed: 11/02/2022]
Abstract
Ontogenetic studies help us understand the processes of evolutionary change. Previous studies on Neandertals have focused mainly on dental development and inferred an accelerated pace of general growth. We report on a juvenile partial skeleton (El Sidrón J1) preserving cranio-dental and postcranial remains. We used dental histology to estimate the age at death to be 7.7 years. Maturation of most elements fell within the expected range of modern humans at this age. The exceptions were the atlas and mid-thoracic vertebrae, which remained at the 5- to 6-year stage of development. Furthermore, endocranial features suggest that brain growth was not yet completed. The vertebral maturation pattern and extended brain growth most likely reflect Neandertal physiology and ontogenetic energy constraints rather than any fundamental difference in the overall pace of growth in this extinct human.
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Affiliation(s)
- Antonio Rosas
- Paleoanthropology Group, Department of Paleobiology, Museo Nacional de Ciencias Naturales (MNCN)-Consejo Superior de Investigaciones Científicas (CSIC), Calle José Gutiérrez Abascal 2, 28006 Madrid, Spain.
| | - Luis Ríos
- Paleoanthropology Group, Department of Paleobiology, Museo Nacional de Ciencias Naturales (MNCN)-Consejo Superior de Investigaciones Científicas (CSIC), Calle José Gutiérrez Abascal 2, 28006 Madrid, Spain.,Department of Physical Anthropology, Aranzadi Society of Sciences, Zorroagagaina 11, 20014 Donostia-San Sebastián, Gipuzkoa, Spain
| | - Almudena Estalrrich
- Paleoanthropology Group, Department of Paleobiology, Museo Nacional de Ciencias Naturales (MNCN)-Consejo Superior de Investigaciones Científicas (CSIC), Calle José Gutiérrez Abascal 2, 28006 Madrid, Spain.,Department of Paleoanthropology, Senckenberg Research Institute and Natural History Museum Frankfurt, Senckenberganlage 25, 60325 Franckfurta, Germany
| | - Helen Liversidge
- Queen Mary University of London, Institute of Dentistry, Turner Street, London E1 2AD, UK
| | - Antonio García-Tabernero
- Paleoanthropology Group, Department of Paleobiology, Museo Nacional de Ciencias Naturales (MNCN)-Consejo Superior de Investigaciones Científicas (CSIC), Calle José Gutiérrez Abascal 2, 28006 Madrid, Spain
| | - Rosa Huguet
- Institut Català de Paleoecologia Humana i Evolució Social-Unidad Asociada al CSIC, Campus Sescelades (Edifici W3), Universitat Rovira i Virgili, Carrer Marcel.lí Domingo s/n, 43007 Tarragona, Spain
| | - Hugo Cardoso
- Department of Archaeology, Simon Fraser University, Burnaby, British Columbia V5A1S6, Canada
| | - Markus Bastir
- Paleoanthropology Group, Department of Paleobiology, Museo Nacional de Ciencias Naturales (MNCN)-Consejo Superior de Investigaciones Científicas (CSIC), Calle José Gutiérrez Abascal 2, 28006 Madrid, Spain
| | - Carles Lalueza-Fox
- Institute of Evolutionary Biology (CSIC-Universitat Pompeu Fabra), Carrer Dr. Aiguader 88, 08003 Barcelona, Spain
| | - Marco de la Rasilla
- Área de Prehistoria Departamento de Historia, Universidad de Oviedo, Calle Teniente Alfonso Martínez s/n, 33011 Oviedo, Spain
| | - Christopher Dean
- Department of Cell and Developmental Biology, University College London, Gower Street, London WC1E 6BT, UK
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Mahmood HT, Shaikh A, Fida M. Association between frontal sinus morphology and cervical vertebral maturation for the assessment of skeletal maturity. Am J Orthod Dentofacial Orthop 2017; 150:637-642. [PMID: 27692421 DOI: 10.1016/j.ajodo.2016.03.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Various methods have been proposed to evaluate a patient's developmental status. However, most of them lacked precision and failed to give a reliable estimate of skeletal maturity. The aims of this study were to evaluate the association between frontal sinus morphology and cervical vertebral maturation for the assessment of skeletal maturity and to determine its validity in assessing the different stages of the adolescent growth spurt. METHODS A cross-sectional study was performed on the pretreatment lateral cephalograms of 252 subjects aged 8 to 21 years. The sample was divided into 6 groups based on the cervical vertebral maturation stages. The frontal sinus index was calculated by dividing the frontal sinus height and width, and the cervical stages were evaluated on the same radiograph. The Kruskal-Wallis test was applied to compare frontal sinus index values at different cervical stages, and the post hoc Dunnett T3 test was applied to compare frontal sinus index values between adjacent cervical stages for each sex. The Kendall tau-b values were computed to assess the correlation between the cervical stages and the sinus index. A P value of ≤0.05 was considered statistically significant. RESULTS The height and width of the frontal sinus were significantly larger in the male subjects than in the females. A significant association was found between the frontal sinus height and width and cervical stages (P ≤0.001) in both sexes. However, the changes in the frontal sinus index across the different cervical stages were found to be significant (P ≤0.001) in male subjects only. Similarly, a weak negative correlation was found between the sinus index and the cervical stages in male subjects (tau-b = -0.271; P <0.001), whereas no correlation was found in female subjects (tau-b = -0.006; P <0.928). However, the post hoc analysis showed that the values of the sinus index were comparable between any 2 adjacent cervical stages. CONCLUSIONS The frontal sinus index cannot be used to identify the prepubertal, pubertal, and postpubertal stages of the adolescent growth spurt. Therefore, it cannot be used as a reliable maturity indicator.
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Affiliation(s)
- Hafiz Taha Mahmood
- Resident in orthodontics, Section of Dentistry, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Attiya Shaikh
- Consultant orthodontist, assistant professor, and program coordinator for the orthodontics residency program, Section of Dentistry, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
| | - Mubassar Fida
- Consultant orthodontist, associate professor, and program director for the orthodontics residency program, Section of Dentistry, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Abstract
BACKGROUND AND AIMS The timing of menarche in Crohn's disease (CD) is poorly described. Our objectives were to study age at menarche onset in CD, and factors associated with this. METHODS We compared the age at menarche of 34 CD patients with that for 545 controls, using data in the National Health and Nutrition Examination Survey (NHANES). RESULTS Mean chronological age (CA) of CD patients (15.6 years) did not differ from that of the NHANES cohort (15.7 years; P = 0.91). The median CA at menarche (13.9 years) in CD was older than in the NHANES sample (12.0 years) (P < 0.00005). In CD patients, the cumulative incidence of menarche was 10 % at CA 12 years, 51 % at CA 14 years, and 100 % at CA 16 years. Sixty-eight percent reached menarche by bone age (BA) 13.5 years and 100 % by BA greater than 14.0 years. Menarche occurred earliest in South Asians, followed by East Asians, and then Caucasians (P = 0.02). CONCLUSIONS CA at menarche is delayed in CD compared with the NHANES cohort. BA at menarche in CD is similar to BA at menarche reported for healthy children. CA at menarche in CD differs by race. If menarche has not occurred by BA greater than 14.0 years, endocrinology referral should be considered.
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