How Long Can You Delay? Curve Progression While Awaiting Vertebral Body Tethering Surgery

Background: The implications of delaying surgical intervention for patients with adolescent idiopathic scoliosis (AIS) wishing to undergo vertebral body tethering (VBT) have not yet been explored. It is important to understand how these delays can impact surgical planning and patient outcomes. Methods: This was a retrospective review that analyzed all AIS patients treated between 2015 and 2021 at a single tertiary center. Time to surgery from initial surgical consultation and ultimate surgical plan were assessed. Patient characteristics, potential risk factors associated with increased curve progression, and reasons for delay were also analyzed. Results: 174 patients were evaluated and 95 were scheduled for VBT. Four patients later required a change to posterior spinal fusion (PSF) due to excessive curve progression. Patients requiring PSF were shown to have significantly longer delays than those who received VBT. Additionally, longer delays, younger age, greater curve progression, and lower skeletal maturity were correlated with significant curve progression (≥5 degrees). Conclusions: Surgical delays for AIS patients awaiting VBT may lead to significant curve progression and necessitate more invasive procedures. Patients with longer delays experienced an increased risk of needing PSF instead of VBT. Of those requiring PSF, the majority were due to insurance denials. Optimizing surgical timing and shared decision-making among patients, families, and healthcare providers are essential for achieving the best outcomes.

Specialist learning curves and clinical feasibility of introducing a new MRI grading system for skeletal maturity

Objective

MRI is an emerging imaging modality to assess skeletal maturity. This study aimed to chart the learning curves of paediatric radiologists when using an unfamiliar MRI grading system of skeletal maturity and to assess the clinical feasibility of implementing said system.

Methods

958 healthy paediatric volunteers were prospectively included in a dual-facility study. Each subject underwent a conventional MRI scan at 1.5 T. To perform the image reading, the participants were grouped into five subsets (subsets 1-5) of equal size (n∼192) in chronological order for scan acquisition. Two paediatric radiologists (R1-2) with different levels of MRI experience, both of whom were previously unfamiliar with the study's MRI grading system, independently evaluated the subsets to assess skeletal maturity in five different growth plate locations. Congruent cases at blinded reading established the consensus reading. For discrepant cases, the consensus reading was obtained through an unblinded reading by a third paediatric radiologist (R3), also unfamiliar with the MRI grading system. Further, R1 performed a second blinded image reading for all included subjects with a memory wash-out of 180 days. Weighted Cohen kappa was used to assess interreader reliability (R1 vs consensus; R2 vs consensus) at non-cumulative and cumulative time points, as well as interreader (R1 vs R2) and intrareader (R1 vs R1) reliability at non-cumulative time points.

Results

Mean weighted Cohen kappa values for each pair of blinded readers compared to consensus reading (interreader reliability, R1-2 vs consensus) were ≥0.85, showing a strong to almost perfect interreader agreement at both non-cumulative and cumulative time points and in all growth plate locations. Weighted Cohen kappa values for interreader (R1 vs R2) and intrareader reliability (R1 vs R1) were ≥0.72 at non-cumulative time points, with values ≥0.82 at subset 5.

Conclusions

Paediatric radiologists' clinical confidence when introduced to a new MRI grading system for skeletal maturity was high from the outset of their learning curve, despite the radiologists' varying levels of work experience with MRI assessment. The MRI grading system for skeletal maturity investigated in this study is a robust clinical method when used by paediatric radiologists and can be used in clinical practice.

Advances in knowledge

Radiologists with fellowship training in paediatric radiology experienced no learning curve progress when introduced to a new MRI grading system for skeletal maturity and achieved desirable agreement from the first time point of the learning curve. The robustness of the investigated MRI grading system was not affected by the earlier different levels of MRI experience among the readers.

Assessment of Skeletal Maturity in a Sample of the Saudi Population Using Cervical Vertebrae and Frontal Sinus Index: A Cephalometric Study Using Artificial Intelligence

Aim This study aims to investigate the relationship between the frontal sinus index and different stages of cervical vertebral maturation and to determine whether these measurements can be used as accurate markers for evaluating skeletal maturity. Materials and methods The sample size was 120 subjects, with ages that ranged from 8 to 25 years. Standardized pretreatment digital lateral cephalograms were analyzed. Six groups representing different phases of cervical vertebral maturation were created from the entire sample. Each group had 20 subjects and was split into male and female groups. On the same radiograph, the cervical stages were assessed and the frontal sinus index was calculated. Correlations between the frontal sinus index and cervical vertebral maturation were assessed using statistical analysis. Results Sinus index values, which assess the ratio of frontal sinus dimensions to cervical stages, were found to be comparable between the two adjacent cervical stages. However, the patterns of sinus index values differed between males and females, suggesting potential variations in sinus development between the sexes. Conclusion Frontal sinus height and width were significantly correlated with cervical vertebral maturation stages in both sexes. The frontal sinus index, on the other hand, was not significant.

Evaluation of Cervical Vertebral Maturation Angular Measurements as a Tool to Assess Skeletal Maturity: A Radiological Study

Aim

The purpose of the present research was to evaluate the comparison between the Skeletal Maturation phases of Fishman's hand-wrist skeletal maturation index (SMI) and cervical vertebral maturation angle (CVMA).

Methodology

Assessment and comparison of Skeletal Maturation utilizing the hand-wrist bone radiograph by Fishman's system of skeletal maturation indicator (SMI), cervical vertebra maturation stages (CVMS), and lateral cephalogram by cervical vertebral maturation angle (CVMA) conducted on 150 subjects (75 male and 75 female). Chi-square was used to reveal the significance of study parameters on a categorical scale between SMI, CVMS, CVMA, and multiple regression analysis conducted to envisage the connotation of the dependent variable.

Results

Multiple regression analysis models exhibited 61.9% of the variance for CVMA with autonomous variables. In multiple regression analysis, there is no substantial association (P > 0.05) between age and CVMA. The correlation of SMI and CVMA values utilizing Pearson's correlation coefficient for males and females presented positive association with R value of 0.801 for males and 0.834 for females and a P value of < 0.001.

Conclusion

As compared to other maturity indicators like hand and wrist, cervical vertebral angular measurements were reliable enough for assessing the degree of skeletal maturation.

[Age assessment using CT of knee joint and neural network technologies]

Age assessment of living persons plays an important role in clinical and sports medicine, as well as in law practice. Traditional methods have a number of problems: age restrictions, technical difficulties of visualization, low reproducibility and subjectivity of estimation. The proposed approach, which implies the use of multispiral computed tomography (MSCT) and database mining, will eliminate these drawbacks and improve the estimation of age. The aim of the study was to investigate the use of deep learning algorithms to classify the age groups (with a threshold level of 18 years) for CT images of knee joint. The study included 455 MSCT images of the knee joint of male and female subjects aged from 13 to 24. The method included score assessment of the distal femur's epiphyseal synostosis stages, tibia and fibula proximal epiphyses and a preliminary statistical analysis of correlations between age and stages of synostosis. The challenge of binary classification of target age groups with the use of convolutional neural networks was implemented at the second phase of the trial. Various architectures of convolutional neural networks and their ensembles were tested. The result of the study showed that the total score of epiphyseal synostosis has the highest correlation with the age (r=0.88). The proposed method of chronological age assessment on the basis of the knee area CT images research using deep learning algorithms demonstrated a good result. The classification accuracy (threshold level of 18 years) was 0.86.

The Interrater and Intrarater Reliability of the Humeral Head Ossification System and the Proximal Femur Maturity Index Assessments for Patients with Adolescent Idiopathic Scoliosis

Background

Skeletal maturity can evaluate the growth and development potential of children and provide a guide for the management of adolescent idiopathic scoliosis (AIS). Recent studies have demonstrated the advantages of the Humeral Head Ossification System (HHOS) and the Proximal Femur Maturity Index (PFMI), based on standard scoliosis films, in the management of AIS patients. We further assessed the HHOS and the PFMI method's reliability in the interrater and intrarater.

Methods

The data from 38 patients, including the humeral head and proximal femur on standard scoliosis films, were distributed to the eight raters in the form of a PowerPoint presentation. On 38 independent standard spine radiographs, raters utilized the HHOS and PFMI to assign grades. The PPT sequence was randomly changed and then reevaluated 2 weeks later. For every system, the 95% confidence interval (95% CI) and intraclass correlation coefficient (ICC) were calculated to evaluate the interrater and intrarater reliability.

Results

The HHOS was extremely reliable, with an intraobserver ICC of 0.802. In the first round, the interobserver ICC reliability for the HHOS was 0.955 (0.929-0.974), while in the second round, it was 0.939 (0.905-0.964). The PFMI was extremely reliable, with an intraobserver ICC of 0.888. In the first round, the interobserver ICC reliability for the PFMI was 0.967 (0.948-0.981), while in the second round, it was 0.973 (0.957-0.984).

Conclusions

The HHOS and PFMI classifications had excellent reliability. These two methods are beneficial to reduce additional exposure to radiation and expense for AIS. There are advantages and disadvantages to each classification. Clinicians should choose a personalized and reasonable method to assess skeletal maturity, which will assist in the management of adolescent scoliosis patients.

Bone age assessment from lateral cephalograms using deep learning algorithms in the Indian population

Purpose

The assessment of bone age has applications in a wide variety of fields: from orthodontics to immigration. The traditional non-automated methods are time-consuming and subject to inter- and intra-observer variability. This is the first study of its kind done on the Indian population. In this study, we analyse different pre-processing techniques and architectures to determine the degree of maturation (i.e. cervical vertebral maturation [CVM]) from cephalometric radiographs using machine learning algorithms.

Methods

Cephalometric radiographs-labelled with the correct CVM stage using Baccetti et al. method-from 383 individuals aged between 10 and 36 years were used in the study. Data expansion and in-place data augmentation were used to handle high data imbalances. Different pre-processing techniques like Sobel filters and canny edge detectors were employed. Several deep learning convolutional neural network (CNN) architectures along with numerous pre-trained models like ResNet-50 and VGG-19 were analysed for their efficacy on the dataset.

Results

Models with 6 and 8 convolutional layers trained on 64 × 64-size grayscale images trained the fastest and achieved the highest accuracy of 94%. Pre-trained ResNet-50 with the first 49 layers frozen and VGG-19 with 10 layers frozen to training had remarkable performances on the dataset with accuracies of 91% and 89%, respectively.

Conclusions

Custom deep CNN models with 6-8 layers on 64 × 64-sized greyscale images were successfully used to achieve high accuracies to classify the majority classes. This study is a launchpad in the development of an automated method for bone age assessment from lateral cephalograms for clinical purposes.

The Spectrum of Anterior Cruciate Ligament Reconstruction Options for the Pediatric and Adolescent Patient: A Narrative Review

As youth sports participation has increased in recent years, injuries to the anterior cruciate ligament (ACL) have become increasingly common in pediatric patients. Historically, ACL reconstruction was delayed in pediatric patients to avoid physeal damage with the potential for leg-length discrepancy or angular deformity. Current research shows that delaying reconstruction or choosing nonoperative management is associated with increased rates of meniscal and chondral injuries, persistent knee instability, and low rates of return to previous activity. Early ACL reconstruction using techniques to avoid physeal growth disturbance is now widely accepted among physicians. The purpose of this review was to describe the pediatric ACL in terms of the relevant anatomy and biomechanics, physical examination, and diagnostic imaging. In addition, the importance of skeletal age and possible physeal injury is discussed in the context of ACL reconstruction options by skeletal age and remaining growth potential.

Deformation behaviors and mechanical impairments of tissue cracks in immature and mature cartilages

Degeneration of articular cartilage is often triggered by a small tissue crack. As cartilage structure and composition change with age, the mechanics of cracked cartilage may depend on the tissue age, but this relationship is poorly understood. Here, we investigated cartilage mechanics and crack deformation in immature and mature cartilage exposed to a full-thickness tissue crack using indentation testing and histology, respectively. When a cut was introduced, tissue cracks opened wider in the mature cartilage compared to the immature cartilage. However, the opposite occurred upon mechanical indentation over the cracked region. Functionally, the immature-cracked cartilages stress-relaxed faster, experienced increased tissue strain, and had reduced instantaneous stiffness, compared to the mature-cracked cartilages. Taken together, mature cartilage appears to withstand surface cracks and maintains its mechanical properties better than immature cartilage and these superior properties can be explained by the structure of their collagen fibrous network.

Association of Salivary IGF and IGF/IGFBP-3 Molar Ratio with Cervical Vertebral Maturation Stages from Pre-Adolescent to Post-Adolescent Transition Period-A Cross-Sectional Exploratory Study

Background: The relevance of growth determination in orthodontics is driving the search for the most precise and least invasive way of tracking the pubertal growth spurt. Objectives: The aim was to explore whether minimally invasive salivary estimation of biomarkers Insulin-like growth factor (IGF-1) and Insulin-like growth factor binding protein-3 (IGFBP-3) could be used to estimate skeletal maturity with diagnostic accuracy, especially in children and adolescent age groups. Subjects and methods: The cross-sectional study was conducted on 105 participants aged 6−25 years from the out-patient Department of Preventive Dental Science at Majmaah University between the period 2 January 2021 and 12 July 2021. Each subject’s lateral cephalogram radiograph was categorized based on skeletal maturity, and saliva samples were estimated for IGF-1 and IGFBP-3 using the respective ELISA kits. Two-way ANOVA with interaction was applied to examine the main effects due to cervical vertebral maturation staging (CVS), Sex and interaction effect due to CVS, and Sex on study parameters. Karl Pearson’s Product Moment Correlation Coefficient was calculated for finding a significant association between IGF, IGFBP3, and the IGF-1/IGFBP3 molar ratio. Results: Highest mean salivary IGF-1 was observed in the pubertal peak stage, which coincides with cervical vertebral maturity stages 3 and 4 (CVS3 and CVS4) for both males (2.57 ng/mL) and females (1.57 ng/mL) and the lowest mean level of IGF-1 for females (0.85 ng/mL) and males (1.22 ng/mL) was observed during the prepubertal stage. There exists a significant variation in IGF-1 between males and females in the pubertal stage (p < 0.01), but the difference is very narrow in the prepubertal and post-pubertal groups (p > 0.05). There was no significant interaction effect of different skeletal stages and gender on the IGFBP3 and the IGF-1/IGFBP3 molar ratio (p > 0.05), but there exists a significant interaction effect on IGF-1 (p < 0.05). Conclusion: Estimation of the IGF-1 and the IGF-1/IGFBP3 molar ratio in saliva, being a non-invasive biological marker, could serve as an adjunctive tool along with radiographic assessment in estimating growth maturity in the adolescence age group. By initiating orthodontic treatment during the mandibular growth peak in adolescence, a positive outcome is ensured in managing skeletal deformities within the craniofacial complex.

Correlation between Salivary Levels of IGF-1, IGFBP-3, IGF-1/IGFBP3 Ratio with Skeletal Maturity Using Hand-Wrist Radiographs

Objective: The relevance of growth determination in orthodontics is driving the search for the most precise and least invasive way of tracking the pubertal growth spurt. Our aim was to explore whether minimally invasive salivary estimation of biomarkers Insulin-like growth factor (IGF-1) and Insulin-like growth factor binding protein-3 (IGFBP-3) could be used to estimate skeletal maturity for clinical convenience, especially in children and adolescent age groups. Materials and Method: The cross-sectional study was conducted on 90 participants (56 girls and 34 males) with ages ranging from 6 to 25 years. Each subject’s hand-wrist radiograph was categorized based on skeletal maturity, and saliva samples were estimated for IGF-1 and IGFBP-3 using the respective ELISA kits. Kruskal−Wallis nonparametric ANOVA was applied to compare different skeletal stages. Results: The study demonstrated low salivary IGF-1 levels at the prepubertal stage, with increase during pubertal onset and peak pubertal stage followed by a decline during pubertal deceleration to growth completion. Spearman’s correlation coefficient demonstrated a strong positive association (r = 0.98 p < 0.01) between salivary IGF/IGFBP-3 ratio and different stages of skeletal maturity. Conclusion: Salivary IGF-1, IGFBP-3, and IGF/IGFBP-3 ratio could serve as a potential biochemical marker for predicting the completion of skeletal maturity.

An apparently phylogeny-independent method for identification of skeletal (longitudinal) growth cessation (skeletal maturity) in birds

Identification of skeletal maturity is of interest as a measure of species longevity and for identifying its maximal achievable size/mass. Measurement of age on the basis of growth arrest/accentuation lines (LAGs) and external fundamental system (EFS) evidences cessation or at least extreme slowing of circumferential bone growth. Such intramembranous (periosteal)-derived growth is distinct from the endochondral ossification responsible for longitudinal growth and therefore achievable organismal size/mass. As subchondral trans-cortical channels are required for nourishment, their loss should identify cessation of longitudinal growth. Predicated on phylogenetic bracketing/relationship and shared anatomical structures with and without growth plates, birds represent an appropriate model for the study of dinosaur ontogeny. Persistence of trans-cortical subchondral channels in the long bones of birds are examined at 100-200X magnification and correlated with bone length. Trans-cortical channels are present in subchondral articular surfaces, but disappear when terminal longitudinal growth is achieved. Articular vascular channels perforating articular surfaces from within the bone are detected. Loss of penetrating channels is interpreted as evidence of skeletal growth cessation, identifying the longitudinal bone length at which skeletal growth cessation has been achieved. The current study provides evidence that maximal bone length does correlate with endochondral cessation growth. Failure of circumferential growth reduction/cessation to correlate with bone length may be related to lack of synchronicity of periosteal-based circumferential growth with the endochondral process responsible for bone lengthening. Loss/closure of articular vascular channels may be the most reliable measure of a bird's achievement of maximal growth (indicating cessation of appendicular element lengthening). This article is protected by copyright. All rights reserved.

Bone age in prepubertal children with nonfamilial or familial idiopathic short stature and prepubertal short-stature children born small for gestational age: a longitudinal data analysis

This retrospective study aimed to clarify the characteristics of bone maturation using longitudinal data in short-stature prepubertal children. Children with chronological ages (CAs) of 4.5–10.5 yr with nonfamilial idiopathic short stature (ISS, n = 95), familial ISS (FSS, n = 21), and short-stature children born small for gestational age (SGA, n = 23) were selected, of which 435 left-hand plain radiographic images were evaluated. Bone age (BA) delay was defined as BA minus CA. In the ISS group, there was a statistically significant difference in median BA delay among the CA groups (P < 0.001), as median BA delay gradually increased from 5- to 9-yr-old groups (−1.06 [range, −2.17 to 0.27] and −2.45 [range, −4.35 to −0.32] yr, respectively). In the FSS group, median BA delays were approximately −1 yr in all CA groups. In the SGA group, median BA delay gradually decreased from 7- to 10-yr-old groups (−1.96 [range, −2.99 to 0.56] and −0.04 [range, −2.44 to 0.92] yr, respectively), but with no significant difference (P = 0.647). The heavier weight of children with FSS and the probable earlier onset of adrenarche in children born SGA compared to those with ISS could have affected bone maturation.

Prediction of Final Body Height for Female Patients With Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To explore the possibility of predicting final body height at maturity based on associating parameters at the time of diagnosing adolescent idiopathic scoliosis (AIS), while examining the effect of curve magnitude and deterioration.

METHODS

A total of 284 female patients with AIS (mean age 12.2 ± 1.1 years, 52.5% premenarchal) were followed till skeletal maturity, indicated by ≥Risser stage 4, static body height and arm span over the past 6 months, and postmenarche 2 years. Standing body height, arm span, menarchal status, Risser staging, distal radius and ulna (DRU) classification, Sanders staging (SS), Cobb angles (major and minor curves), and Lenke curve types at initial presentation were examined. Patients with/without curve deterioration were compared. Multiple linear regression was used for predicting final body height (cm), and remaining height increase (%).

RESULTS

Baseline body height was 152.1 ± 7.1 cm and major curve Cobb angle was 27.1° ± 7.4°, whereas at maturity they were 159.5 ± 5.4 cm and 32.5° ± 9.3°, respectively. For patients presented at Risser stage 0 or 1, radius grade (R) 6, ulnar grade (U) 5, or SS3, those with curve deterioration exhibited greater height increase potential at initial presentation (P < .05) than those without deterioration. No intergroup difference was found for patients presented at ≥Risser 2, R7, U6, SS4. Predictive baseline parameters were age, body height, Cobb angle (major curve), curve type, and DRU grades. Prediction models of final body height (R ² = 0.735, P < .001) and remaining height increase (R ² = 0.742, P < .001) were established.

CONCLUSIONS

Final body height prediction model was derived for female patients with AIS, with baseline body height and ulnar grading having larger impacts than other parameters.

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

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.

Correlation between Insulin-Like Growth Factor I and Skeletal Maturity Indicators

Objective: The purpose of this study was to evaluate the correlation between the growth maturity indicators in orthodontic patients. Design: This cross-sectional study was performed on 37 orthodontic patients (17 males and 20 females). An anamnesis, clinical and image examination, and blood sample collection were performed. The inclusion criteria were non-syndromic Class II patients of both gender, age ranging between 10 to 16 years. The lateral cephalometric radiographs were evaluated using 6-stage cervical vertebrae maturation (CVM) technique. The hand-wrist radiographs were staged using the 11-stage skeletal maturation indicator (SMI) technique. Blood was collected in the same week of the images to quantify IGF-1 levels in serum. Data were tested for normality by Shapiro–Wilk test. The Pearson test was used to determine the correlation strength between the variables (alpha of 5%). Results: A strong correlation was observed only between SMI stages and CVM stages in the total sample (r=0.864; p<0.0001) and according to the gender (r=0.793; p<0.0001 for females; and r=0.753; p<0.0001 for males). IGF-1 was only moderately correlated with SMI stages and CVM stages. Conclusion: Hand-wrist and cervical vertebral stages were strongly correlated among them, however, IGF-1 was only moderately correlated with both skeletal maturity indicators.

Assessment of the Relationship between Skeletal Maturity and the Calcifications Stages of Permanent Canines and Second Premolars

Objective

This study aimed to evaluate the relationship between the calcification stages of permanent maxillary and mandibular canines and second premolars and skeletal maturity in both sexes.

Methods

This study included 138 patients (82 females, 56 males) who were treated in the Department of Orthodontics, Altınbaş University. The mean age of the patients was 12.31±1.76 years, ranging from 7.8 years to 15.8 years. Dental maturity stages of canines and second premolars were evaluated according to the Demirjian index on digital panoramic radiograph. The skeletal maturation stage was determined using the cervical vertebral maturation (CVM) index. The Pearson correlation analysis was performed to assess the association among CVM stages and calcification stages of canines, second premolars, sex, and chronological ages.

Results

A statistically significant correlation was found between CVM and the calcification stages of the canines and second premolars (p<0.05). The calcification stages of the canines and second premolars had the highest distribution of Stage F and Stage G at CVM2 (p<0.01). For the canines and second premolars, Stage H corresponded to CVM3 in female patients and a high percentage of Stage G corresponded to CVM3 in the male group.

Conclusion

A significant correlation was found between the calcification stages of maxillary and mandibular canines, second premolars, and skeletal maturity in both sexes. It was observed that calcification stages and cervical maturations were advanced in female subjects compared with male subjects.

Chronological Age in Different Bone Development Stages: A Retrospective Comparative Study

The assessment of an individual's development by investigating the skeletal maturity is of much use in various medical fields. Skeletal maturity can be estimated by evaluating the morphology of the cervical vertebrae. The aim of this study was to conduct comparisons of the chronological age in different bone development stages. The retrospective study was conducted based on lateral cephalometric radiographs belonging to patients with ages between 6 and 15.9 years, from Romania. For the assessment of skeletal maturity, the Cervical Vertebral Maturation (CVM) method was used. In total, 356 radiographs were selected, but after applying the exclusion criteria, 252 radiographs remained in the study (178 girls and 74 boys). Different mean chronological age values were obtained for the general sample, as well as for the two genders. The chronological age started to be significantly different at the CS4 stage. Patients with CS4, CS5, and CS6 stages had a significantly higher chronological age compared to patients with CS1, CS2, and CS3 stages. It was noted that patients with CS1 and CS2 stages were more frequently boys, while patients with the CS5 stage were more frequently girls.

Chronological Age Assessment in Young Individuals Using Bone Age Assessment Staging and Nonradiological Aspects: Machine Learning Multifactorial Approach

BACKGROUND

Bone age assessment (BAA) is used in numerous pediatric clinical settings as well as in legal settings when entities need an estimate of chronological age (CA) when valid documents are lacking. The latter case presents itself as critical as the law is harsher for adults and granted rights along with imputability changes drastically if the individual is a minor. Traditional BAA methods have drawbacks such as exposure of minors to radiation, they do not consider factors that might affect the bone age, and they mostly focus on a single region. Given the critical scenarios in which BAA can affect the lives of young individuals, it is important to focus on the drawbacks of the traditional methods and investigate the potential of estimating CA through BAA.

OBJECTIVE

This study aims to investigate CA estimation through BAA in young individuals aged 14-21 years with machine learning methods, addressing the drawbacks of research using magnetic resonance imaging (MRI), assessment of multiple regions of interest, and other factors that may affect the bone age.

METHODS

MRI examinations of the radius, distal tibia, proximal tibia, distal femur, and calcaneus were performed on 465 men and 473 women (aged 14-21 years). Measures of weight and height were taken from the subjects, and a questionnaire was given for additional information (self-assessed Tanner Scale, physical activity level, parents' origin, and type of residence during upbringing). Two pediatric radiologists independently assessed the MRI images to evaluate their stage of bone development (blinded to age, gender, and each other). All the gathered information was used in training machine learning models for CA estimation and minor versus adult classification (threshold of 18 years). Different machine learning methods were investigated.

RESULTS

The minor versus adult classification produced accuracies of 0.90 and 0.84 for male and female subjects, respectively, with high recalls for the classification of minors. The CA estimation for the 8 age groups (aged 14-21 years) achieved mean absolute errors of 0.95 years and 1.24 years for male and female subjects, respectively. However, for the latter, a lower error occurred only for the ages of 14 and 15 years.

CONCLUSIONS

This study investigates CA estimation through BAA using machine learning methods in 2 ways: minor versus adult classification and CA estimation in 8 age groups (aged 14-21 years), while addressing the drawbacks in the research on BAA. The first achieved good results; however, for the second case, the BAA was not precise enough for the classification.

Cervical vertebral maturation (CVM) stage as a supplementary indicator for the assessment of peak height velocity (PHV) in adolescent idiopathic scoliosis (AIS)

BACKGROUND

Radiographic methods in evaluating the skeletal maturity include Risser sign and Tanner-Whitehouse score. They are either inappropriate or too complex for a busy clinic setting. The cervical vertebral maturation (CVM) stage is commonly used in orthodontics but has been less acknowledged in studies of spinal growth. The purpose of this study was to evaluate whether the CVM stage could be used as an alternative to Risser sign in determining peak height velocity (PHV).

METHODS

This was a two-stage study. Inclusion criteria for stage I study were adolescent female idiopathic scoliosis (AIS) patients, aged between 9-16 years old, who had undergone full spine imaging with clear visibility of the cervical spine. Patients in the stage II study had follow-up through CVM stage 2-4. The correlation between CVM and Risser was analyzed. The spinal growth parameters were measured at each follow-up, and the growth velocity of parameters (PaGVs) was calculated. The PaGVs at CVM stage 2-4 were further compared.

RESULTS

A total of 170 AIS patients were included for stage I study (mean age 12.7 years). The CVM stages were found to correlate strongly with the Risser sign (r=0.85, P<0.01). For those patients with Risser stage 0 with closed TC, 71% were CVM stage 3. Fifty-one patients were included for stage II study. The stature growth velocity averaged 5.4 cm/year in CVM stage 2 patients and 6.3 cm/year in CVM stage 3 patients, which was significantly greater growth than that in CVM stage 4 patients (3.3 cm/year, both P<0.01); similarly, the growth velocity of arm span, trunk height, and spinal lengths were also significantly higher in CVM stage 3 patients compared to CVM stage 2 and 4 patients.

CONCLUSIONS

The CVM stage could provide an alternative option for the assessment of skeletal maturity of subjects with idiopathic scoliosis. CVM stage 3 may be a new sign of PHV.

Age Assessment of Youth and Young Adults Using Magnetic Resonance Imaging of the Knee: A Deep Learning Approach

BACKGROUND

Bone age assessment (BAA) is an important tool for diagnosis and in determining the time of treatment in a number of pediatric clinical scenarios, as well as in legal settings where it is used to estimate the chronological age of an individual where valid documents are lacking. Traditional methods for BAA suffer from drawbacks, such as exposing juveniles to radiation, intra- and interrater variability, and the time spent on the assessment. The employment of automated methods such as deep learning and the use of magnetic resonance imaging (MRI) can address these drawbacks and improve the assessment of age.

OBJECTIVE

The aim of this paper is to propose an automated approach for age assessment of youth and young adults in the age range when the length growth ceases and growth zones are closed (14-21 years of age) by employing deep learning using MRI of the knee.

METHODS

This study carried out MRI examinations of the knee of 402 volunteer subjects-221 males (55.0%) and 181 (45.0%) females-aged 14-21 years. The method comprised two convolutional neural network (CNN) models: the first one selected the most informative images of an MRI sequence, concerning age-assessment purposes; these were then used in the second module, which was responsible for the age estimation. Different CNN architectures were tested, both training from scratch and employing transfer learning.

RESULTS

The CNN architecture that provided the best results was GoogLeNet pretrained on the ImageNet database. The proposed method was able to assess the age of male subjects in the range of 14-20.5 years, with a mean absolute error (MAE) of 0.793 years, and of female subjects in the range of 14-19.5 years, with an MAE of 0.988 years. Regarding the classification of minors-with the threshold of 18 years of age-an accuracy of 98.1% for male subjects and 95.0% for female subjects was achieved.

CONCLUSIONS

The proposed method was able to assess the age of youth and young adults from 14 to 20.5 years of age for male subjects and 14 to 19.5 years of age for female subjects in a fully automated manner, without the use of ionizing radiation, addressing the drawbacks of traditional methods.

Sequential spine-hand radiography for assessing skeletal maturity with low radiation EOS imaging system for bracing treatment recommendation in adolescent idiopathic scoliosis: a feasibility and validity study

PURPOSE

The EOS-imaging system is increasingly adopted for clinical follow-up in scoliosis with the advantages of simultaneous biplanar imaging of the spine in an erect position. Skeletal maturity assessment using a hand radiograph is an essential adjunct to spinal radiography in scoliosis follow-up. This study aims at testing the feasibility and validity of a newly proposed EOS workflow with sequential spine-hand radiography for skeletal maturity assessment and bracing recommendation.

METHODS

EOS spine-hand radiographs from patients with diagnosis of idiopathic scoliosis, including both sexes and an age range of ten to 14 years, were scored using the Thumb Ossification Composite Index (TOCI), Sanders and Risser methods. Intraclass correlation coefficients (ICCs) were calculated for inter/intraobserver agreement and were tested with Cronbach's alpha values.

RESULTS

In all, 60 EOS-spine hand radiographs selected from subjects with diagnosis of adolescent idiopathic scoliosis (AIS), including 32 male patients (mean age 11.53 years; 10 to 14) and 28 female patients (mean age 11.50 years; 10 to 13) who underwent sequential spine-hand low dose EOS imaging were generated for analysis. The overall interobserver (ICC = 0.997) and intraobserver agreement (α > 0.9) demonstrated excellent agreement for TOCI staging; ICC > 0.994 for both TOCI and Sanders staging comparing traditional digital versus EOS hand radiography; ICC ≥ 0.841 for agreement on bracing recommendation among TOCI versus the Risser and Sanders system.

CONCLUSION

With the proposed new EOS workflow it was feasible to produce high image quality for skeletal maturity assessment with excellent reliability and validity to inform consistent bracing recommendation in AIS. The workflow is applicable for busy daily clinic settings in tertiary scoliosis centres with reduced time cost, improved efficiency and throughput of the radiology department.

LEVEL OF EVIDENCE

III.

Calibration of life history traits with epiphyseal closure, dental eruption and bone histology in captive and wild red deer

The study of skeletochronology and bone tissue as a record of information on ontogenetic stages and events is widely used for improving the knowledge about life histories (LHs) of extinct and extant vertebrates. Compared with dinosaurs and extant reptiles, mammalian bone histology has received little attention. Here, we calibrate for the first time bone and dental age with histological bone characteristics and LH stages in ontogenetic series of red deer. We rely on known LHs of different aged individuals of captive Cervus elaphus hippelaphus from Austria to correlate epiphyseal closure, dental eruption pattern, bone growth marks and bone tissue patterns in femora and tibiae, and of wild Cervus elaphus hispanicus from Spain. Our data show that females (of both subspecies) attain skeletal maturity earlier than males. At this moment, epiphyseal closure (in femora and tibiae) and dental eruption are complete and long bones start to deposit an external fundamental system. The results also show that the attainment of reproductive maturity in red deer occurs slightly before skeletal maturity.

Identification of bone-specific alkaline phosphatase in saliva and its correlation with skeletal age

Context

Bone-specific alkaline phosphatase (B-ALP), a product of osteoblasts, is a bone formation marker whose serum levels fluctuate with puberty and adolescence.

Aims

This study aims to assess B-ALP levels in saliva and correlate it with different skeletal maturity stages of hand-wrist radiographs using Hagg and Taranger method.

Settings and Design

Observational study and cross-sectional design.

Subjects and Methods

Total sample comprised of 90 individuals, right hand-wrist radiographs, and 2 ml unstimulated whole saliva samples taken from each patient on the same day. The hand-wrist radiographs were traced and staged into 5 subgroups (18 individuals each) according to Hagg and Taranger method.

Statistical Analysis Used

One-way analysis of variance (ANOVA) and Tukey's multiple post hoc test.

Results

The comparison of salivary B-ALP values between the different skeletal subgroups using one-way ANOVA depicted statistically significant results (P = 0.0003). Pairwise comparison using Tukey's multiple post hoc procedures showed that salivary B-ALP levels were comparatively higher in subgroup 3 and that the difference between subgroups 1 and 3 (P = 0.0109) and subgroups 3 and 5 (P = 0.0014) was statistically significant.

Conclusion

B-ALP could be successfully identified and quantitatively estimated in saliva and showed significant correlation with different skeletal age subgroups as determined by Hagg and Taranger method.

Binary and analogue markers of skeletal maturity: clinical utility of the thenar and plantar sesamoids

PURPOSE

We investigate the thenar and plantar sesamoids as markers of skeletal maturity, and grade appearance using two scales, a binary system (absent or present), and an analogue system that relies upon judging regular changes in morphological appearance.

METHODS

We studied 94 healthy children (49 female and 45 male patients) between ages three and 18 years who had approximately 700 serially acquired sets of radiographs and physical examinations. The children had at least annual radiographs taken of the left hand and left foot. Velocity of growth was calculated and curves were fit to a cubic spline model to determine age of maximum height velocity, or peak height velocity (PHV). Appearance of the plantar and thenar sesamoids was recorded using a binary system classifying the sesamoids as absent or present and an analogue system classifying the sesamoid as absent, present as a small ossification centre or larger than a small ossification centre.

RESULTS

The plantar sesamoids appear 1.67 years before PHV and reach mature size 1.02 years after PHV. The thenar sesamoids appear 0.32 years before PHV and reach mature size 2.25 years after PHV. The plantar sesamoids are present and thenar sesamoids are absent at a mean 1.5 years prior to PHV. No patients had the thenar sesamoids present while the plantar sesamoids were absent.

CONCLUSION

As binary markers, when the plantar and thenar sesamoids are considered together it is possible to localize maturity. As analogue markers, they offer more information. The sesamoids also allow clarification of the calcaneal and Sanders stages.

LEVEL OF EVIDENCE

Not Applicable.

Both-Bone Forearm Fractures in Children with Minimum Four Years of Growth Remaining: Can Cast Achieve a Good Outcome at Skeletal Maturity?

Introduction: Both-bone forearm fractures in children can be treated non-operatively with a cast. Most previous studies have shown favourable outcome; however, information on the functional outcome after skeletal maturity is still scanty. Therefore, this study was conducted to determine the functional outcome after skeletal maturity in fractures with at least four years of growth remaining.

Materials and Methods: This retrospective study was conducted from March 2012 until March 2013. Age at the time of fracture was taken as until 10 years for females and until 12 years old for males with at least four years of growth remaining. Fractures occurring in the diaphysis were included in the study. Functional outcomes were assessed at or after skeletal maturity.

Results: Forty-four children fulfilled the criteria. The ages of the youngest and the oldest at the time of fracture was five and 12 years old respectively. Follow-up of the male and female patients were 7.4 years and 5.5 years respectively. There was a significant difference between post-reduction angulation and angulation at skeletal maturity of the radius and ulna (p<0.001). Out of 44 patients, 39 had excellent and five had good functional outcomes. No patient had fair or poor functional outcome. There was no association between the functional outcome and the angulation of forearm bones after skeletal maturity. Age at the time of fracture had a significant association with the functional outcome.

Conclusion: Non-operative treatment of both-bone diaphyseal forearm fractures in a cast has good to excellent functional outcomes in children who still have four years of growth remaining.

Age-Dependent Subchondral Bone Remodeling and Cartilage Repair in a Minipig Defect Model

After cartilage injury and repair, the subchondral bone plate remodels. Skeletal maturity likely impacts both bone remodeling and inherent cartilage repair capacity. The objective of this study was to evaluate subchondral bone remodeling as a function of injury type, repair scenario, and skeletal maturity in a Yucatan minipig model. Cartilage defects (4 mm) were created bilaterally in the trochlear groove. Treatment conditions included a full thickness chondral defect (full chondral defect, n = 3 adult/3 juvenile), a partial thickness (∼50%) chondral defect (PCD, n = 3/3), and FCD treated with microfracture (MFX, n = 3/3). At 6 weeks postoperatively, osteochondral samples containing the lesion site were imaged by micro-computed tomography (CT) and analyzed by histology and immunohistochemistry. Via micro-CT, FCD and MFX groups showed increased bone loss in juveniles compared with adults. Quantification of histology using the ICRS II scoring system showed equal overall assessment for the FCD groups and better overall assessment in juvenile animals treated with MFX compared with adults. All FCD and MFX groups were inferior to control samples. For the PCD injury, both age groups had values close to the control values. For the FCD groups, there were greater alterations in the subchondral bone in juveniles compared with adults. Staining for collagen II showed more intense signals in juvenile FCD and MFX groups compared with adults. This large animal study of cartilage repair shows the significant impact of skeletal maturity on the propensity of subchondral bone to remodel as a result of chondral injury. This will improve selection criteria for animal models for studying cartilage injury, repair, and treatment.

Characterising the proximal patellar tendon attachment and its relationship to skeletal maturity in adolescent ballet dancers

Background

It is unknown how and when the proximal attachment of the patellar tendon matures; puberty may be key in ensuring normal tendon formation. The aim of this study was to investigate the features of the proximal patellar tendon attachment at different stages of skeletal maturity, to help gain an understanding of how and when the tendon attachment matures.

Methods

Sixty adolescent elite ballet students (ages 11-18) and eight mature adults participated. Peak height velocity (PHV) estimated skeletal maturity. Ultrasound tissue characterisation (UTC) scan was taken of the left knee and analysed for stability of echopattern. An image-based grading scale for greyscale ultrasound was developed to describe the tendon appearance. Anterior-posterior thickness was measured at the inferior pole of the patella, 1 and 2 centimetres distally. Outcomes were compared with skeletal maturity.

Results

Mid-portion patellar tendon thickness increased with skeletal maturity (p=0.001 at 1 cm and p=0.007 at 2 cm). There was more variance in structural appearance (greyscale classification and UTC echopattern) in pre and peri-PHV participants. Tendon attachment one-year post PHV appeared similar to mature tendons.

Conclusions

Early adolescence was associated with highly variable tendon appearance, whereas the tendon appeared mature after PHV. Adolescence may be a critical time for the formation of normal tendon attachment.

Level of evidence

IIb individual cohort study.

Biological and environmental determinants of 12-minute run performance in youth

BACKGROUND

The 12-minute run is a commonly used indicator of cardiorespiratory fitness in youth. Variation in growth and maturity status as potential correlates of test performance has not been systematically addressed.

AIM

To evaluate biological and environmental determinants of 12-minute run performance in Portuguese youth aged 7-17 years.

SUBJECTS AND METHODS

Mixed-longitudinal samples of 187 boys and 142 girls were surveyed in 1996, 1997 and 1998. The 12-minute run was the indicator of cardiorespiratory fitness. Height, body mass and five skinfolds were measured and skeletal maturity was assessed. Physical activity, socioeconomic status and area of residence were obtained with a questionnaire. Multi-level modelling was used for the analysis.

RESULTS

Chronological age and sum of five skinfolds were significant predictors of 12-minute run performance. Older boys and girls ran longer distances than younger peers, while high levels of subcutaneous fat were associated with shorter running distances. Rural boys were more proficient in the 12-minute run than urban peers. Skeletal maturity, height, body mass index, physical activity and socioeconomic status were not significant predictors of 12-minute run performances.

CONCLUSIONS

Age and sum of skinfolds in both sexes and rural residence in boys are significant predictors of 12-minute run performance in Portuguese youth.

Five radiographic methods for assessing skeletal maturity in a Spanish population: is there a correlation?

OBJECTIVES

The need for accurate techniques of estimating age has sharply increased in line with the rise in illegal migration and the political, economic and socio-demographic problems that this poses in developed countries today. The methods routinely employed for determining chronological age are mainly based on determining skeletal maturation using radiological techniques. The objective of this study was to correlate five different methods for assessing skeletal maturation.

MATERIALS AND METHODS

606 radiographs of growing patients were analyzed, and each patient was classified according to two cervical vertebral-based methods, two hand-wrist-based methods and one tooth-based method. Spearman's rank-order correlation coefficient was applied to assess the relationship between chronological age and the five methods of assessing maturation, as well as correlations between the five methods (p < 0.05).

RESULTS

Spearman's rank correlation coefficients for chronological age and cervical vertebral maturation stage using both methods were 0.656/0.693 (p < 0.001), respectively, for males. For females, the correlation was stronger for both methods. The correlation coefficients for chronological age against the two hand-wrist assessment methods were statistically significant only for Fishman's method, 0.722 (p < 0.001) and 0.839 (p < 0.001), respectively for males and females.

CONCLUSIONS

The cervical vertebral, hand-wrist and dental maturation methods of assessment were all found to correlate strongly with each other, irrespective of gender, except for Grave and Brown's method. The results found the strongest correlation between the second molars and females, and the second premolar and males.

CLINICAL RELEVANCE

This study sheds light on and correlates with the five radiographic methods most commonly used for assessing skeletal maturation in a Spanish population in southern Europe.

Evaluation of skeletal maturation using mandibular third molar development in Indian adolescents

Objective:

This study was done with the following objectives: to estimate dental maturity using the Demirjian Index (DI) for the mandibular third molar; to investigate the relationship between dental maturity and skeletal maturity among growing patients; to evaluate the use of the mandibular third molar as an adjunctive tool for adolescent growth assessment in combination with the cervical vertebrae; to evaluate the clinical value of the third molar as a growth evaluation index.

Materials and Methods:

Samples were derived from panoramic radiographs and lateral cephalograms of 615 subjects (300 males and 315 females) of ages ranging 9-18 years, and estimates of dental maturity (DI) and skeletal maturity [cervical vertebrae maturation indicators (CVMI)] were made.

Results:

A highly significant association (r = 0.81 for males and r = 0.72 for females) was found between DI and CVMI. DI Stage B corresponded to Stage 2 of CVMI (prepeak of pubertal growth spurt) in both sexes. In males, DI stages C and D represent the peak of the pubertal growth spurt. In females, stages B and C show that the peak of the pubertal growth spurt has not been passed. DI stage E in females and DI Stage F in males correlate that the peak of the pubertal growth spurt has been passed.

Conclusion:

A highly significant association exists between DI and CVMI. Mandibular third molar DI stages are reliable adjunctive indicators of skeletal maturity.

Correlation of calcification of permanent mandibular canine, mandibular premolars, and permanent mandibular first and second molars with skeletal maturity in Indian population

Context:

Morphological variation in children can be understood by the knowledge of growth and development. The state of dental development can be used in forensic odontology to ascertain the age of an unidentified child.

Aims:

This study aims to investigate the relationship of the stages of calcification of the permanent mandibular canine, mandibular premolars, and permanent mandibular first and second molars with skeletal maturity using panoramic and hand–wrist radiographs.

Settings and Design:

This descriptive work was designed as a cross-sectional study.

Materials and Methods:

The study was conducted on 300 healthy subjects (150 males and 150 females) ranging 7–20 years of age. Demirjian's method and Björk, Grave, and Brown's method were used to correlate teeth calcification and skeletal maturity, respectively.

Statistical Analysis Used:

Descriptive statistics and Spearman's rank correlation coefficient were used.

Results:

1. Correlation coefficients between the skeletal maturity stages and the developmental stages of the five teeth ranged 0.461–0.877 for females and 0.480–0.790 for males. 2. The second molar showed the highest and the first molar showed the lowest relationship for female and male subjects in the Indian population.

Conclusions:

The findings of this study indicate that tooth calcification stages might be clinically used as a maturity indicator of the pubertal growth period.

The relationship of calcaneal apophyseal ossification and Sanders hand scores to the timing of peak height velocity in adolescents

The accurate assessment of skeletal maturity is essential in the management of orthopaedic conditions in the growing child. In order to identify the time of peak height velocity (PHV) in adolescents, two systems for assessing skeletal maturity have been described recently; the calcaneal apophyseal ossification method and the Sanders hand scores. The purpose of this study was to compare these methods in assessing skeletal maturity relative to PHV. We studied the radiographs of a historical group of 94 healthy children (49 females and 45 males), who had been followed longitudinally between the ages of three and 18 years with serial radiographs and physical examination. Radiographs of the foot and hand were undertaken in these children at least annually between the ages of ten and 15 years. We reviewed 738 radiographs of the foot and 694 radiographs of the hand. PHV was calculated from measurements of height taken at the time of the radiographs. Prior to PHV we observed four of six stages of calcaneal apophyseal ossification and two of eight Sanders stages. Calcaneal stage 3 and Sanders stage 2 was seen to occur about 0.9 years before PHV, while calcaneal stage 4 and Sanders stage 3 occurred approximately 0.5 years after PHV. The stages of the calcaneal and Sanders systems can be used in combination, offering better assessment of skeletal maturity with respect to PHV than either system alone.

Reliability Analysis of the Distal Radius and Ulna Classification for Assessing Skeletal Maturity for Patients with Adolescent Idiopathic Scoliosis

Study Design Prospective radiographic study. Objective To test the reliability of the Distal Radius and Ulna Classification (DRU). Methods This single-center study included prospectively recruited subjects with adolescent idiopathic scoliosis managed with bracing. The left-hand radiographs were measured using the DRU classification by two examiners. Intra- and interobserver reliability analysis were performed using intraclass correlation (ICC) analysis. Results From these clinics, 161 patients (124 females and 37 males) with left-hand radiographs were included in the study. The mean age was 13.3 years (standard deviation: 1.5). There was excellent intra- (ICC: 0.93 to 0.95) and interobserver (ICC: 0.97) reliability. Conclusions The DRU classification scheme has been shown to be accurate in determining the peak growth phase and growth cessation. It has now been confirmed to be a reliable tool. Future prospective studies should be performed to investigate its application in deciding when to apply bracing or operative treatment.

Peramorphic traits in the tokay gecko skull

Traditionally, geckos have been conceived to exhibit paedomorphic features relative to other lizards (e.g., large eyes, less extensively ossified skulls, and amphicoelous and notochordal vertebrae). In contrast, peramorphosis has not been considered an important process in shaping their morphology. Here, we studied different sized specimens of Gekko gecko to document ontogenetic changes in cranial anatomy, especially near maturity. Comparison of this species with available descriptions of other geckos resulted in the identification of 14 cranial characteristics that are expressed more strongly with size increase. These characteristics become move evident in later stages of post-hatching development, especially near maturation, and are, therefore, attributed to peramorphosis (hyperossification). ACCTRAN and DELTRAN character optimizations were applied to these characters using a tree of 11 genera derived from a gekkotan molecular phylogeny. This analysis revealed that G. gecko expresses the majority of these putative peramorphic features near maturity, and that some of these features are also expressed in species closely related to G. gecko. The characters studied have the potential to be applied in future phylogenetic and taxonomic studies of this group of lizards.

Unusual Presentation of Giant Cell Tumor in Skeletally Immature Patient in Diaphysis of Ulna

Giant cell tumor is a locally aggressive benign tumor. Giant cell tumor of bone is characteristically found in skeletally mature patient at the end of long bones in the epiphyseal region or epiphysio-metaphyseal region. Giant cell tumor is very rare in skeletally immature patient. But we are presenting a very rare case of giant cell tumor in skeletally immature patient in diaphyseal region which is very uncommon location for giant cell tumor. From this case we concluded that irrespective of the location and skeletal maturity, a giant cell tumor should be diagnosed based on its histology because classical clinical-radiological features are not always present. Index case strengthens this view.

A new system for assessment of growth using mandibular canine calcification stages and its correlation with modified MP3 stages

OBJECTIVE

Orthodontic diagnosis and treatment planning for growing children must involve growth prediction, especially in the treatment of skeletal problems. Studies have shown that a strong association exists between skeletal maturity and dental calcification stages. The present study was therefore taken up to provide a simple and practical method for assessing skeletal maturity using a dental periapical film and standard dental X-ray machine, to compare the developmental stages of the mandibular canine with that of developmental stages of modified MP3 and to find out if any correlation exists, to determine if the developmental stages of the mandibular canine alone can be used as a reliable indicator for assessment of skeletal maturity.

MATERIALS AND METHODS

A total of 160 periapical radiographs, of the mandibular right canine and the MP3 region was taken and assessed according to the Dermirjian's stages of dental calcification and the modified MP3 stages.

RESULTS AND DISCUSSION

The correlation coefficient between MP3 stages and developmental stages of mandibular canine was found to be significant in both male and female groups. When the canine calcification stages were compared with the MP3 stages it was found that with the exception of the D stage of canine calcification the remaining stages showed a very high correlation with the modified MP3 stages.

CONCLUSION

The correlation between the mandibular canine calcification stages, and the MP3 stages was found to be significant. The canine calcification could be used as a sole indicator for assessment of skeletal maturity.

New software for cervical vertebral geometry assessment and its relationship to skeletal maturation--a pilot study

OBJECTIVES

In the present study, we developed new software for quantitative analysis of cervical vertebrae maturation, and we evaluated its applicability through a multinomial logistic regression model (MLRM).

METHODS

Digitized images of the bodies of the second (C2), third (C3) and fourth (C4) cervical vertebrae were analysed in cephalometric radiographs of 236 subjects (116 boys and 120 girls) by using a software developed for digitized vertebrae analysis. The sample was initially distributed into 11 categories according to the Fishman's skeletal maturity indicators and were then grouped into four stages for quantitative cervical maturational changes (QCMC) analysis (QCMC I, II, III and IV). Seven variables of interest were measured and analysed to identify morphologic alterations of the vertebral bodies in each QCMC category.

RESULTS

Statistically significant differences (p < 0.05) were observed among all QCMC categories for the variables analysed. The MLRM used to calculate the probability that an individual belonged to each of the four cervical vertebrae maturation categories was constructed by taking into account gender, chronological age and four variables determined by digitized vertebrae analysis (Ang_C3, MP_C3, MP_C4 and SP_C4). The MLRM presented a predictability of 81.4%. The weighted κ test showed almost perfect agreement (κ = 0.832) between the categories defined initially by the method of Fishman and those allocated by the MLRM.

CONCLUSIONS

Significant alterations in the morphologies of the C2, C3 and C4 vertebral bodies that were analysed through the digitized vertebrae analysis software occur during the different stages of skeletal maturation. The model that combines the four parameters measured on the vertebral bodies, the age and the gender showed an excellent prediction.

Bone age assessment using cephalometric photographs

BACKGROUND

The assessment of bone age comprises the basic element of orthodontic diagnostics as it enables the recognition of deviations from normal growth, determines the choice of treatment, helps determine the appropriate moment to begin treatment, establish prognosis and plan a retention strategy. In order to make an assessment of skeletal maturity possible in a single examination, radiological methods were adopted. The following characteristics are evaluated on a radiograph: the appearance, size and shape of ossification centers, the width and the shape of growth cartilage and the degree of fusion between diaphyses and epiphyses. In order to assess the maturity of bones, hand-wrist radiographs were introduced in the second decade of the 20(th) century. Bone age assessment of bone age could also be made based on an analysis of a morphological maturity of cervical vertebrae utilizing cephalometric radiographs.

OBJECTIVE

The objective of the study was to evaluate the correspondence between bone age assessments made from hand-wrist radiographs and those from cephalometric radiographs.

MATERIAL/METHODS

In order to fulfill the objectives, hand-wrist radiographs as well as cephalometric radiographs of 30 patients (15 girls and 15 boys) between 10 and 17 years of age were collected. Bone age of hand, wrist and cervical spine was assessed. Bone age on hand-wrist radiographs was evaluated using the Björk method, whereas cephalometric radiographs were analyzed by the Baccetti et al. method.

RESULTS

A strong and statistically highly significant (r=0.98; p<0.00001) Pearson's correlation was found between bone age assessed from hand-wrist radiographs using Björk's method and bone age assessed from cephalometric radiographs using the method by Baccetti et al.

CONCLUSIONS

The analysis of cervical vertebrae in cephalometric radiographs appears to be the most desirable method of bone age assessment. Performing the analysis on routinely taken cephalograms eliminates the need for additional exposure to X-ray radiation and shortens the duration of examination.

Mandibular dimensional changes and skeletal maturity

AIM

Growth and development of the human face provides a fascinating interplay of form and function. Among the various facial bones, the mandible plays a very important role during various growth-modification therapies. These treatment modalities will yield a better result in less time if properly correlated with skeletal maturity. It is very essential to know where the site of growth occurs and also the time when it occurs or ceases to occur. This study was conducted to assess the mandibular dimensions at various stages of skeletal maturation.

MATERIALS AND METHODS

The subjects included 6 to 18-year-old children who were grouped according to their middle phalanx of the third finger stages of skeletal maturity. Lateral cephalographs were taken and, from their cephalometric tracings, linear and angular measurements of the mandible were made. The values obtained were subjected to statistical analysis.

RESULTS

Results showed that the mandibular height, length and symphysis thickness increased with skeletal maturity. An increase in angles SNB (Sella, Nasion, Supramentale) and L1-MP (Long axis lower incisors- Mandibular plane) and a decrease in the gonial angle and ANB (Subspinale, Nasion, Supramentale) angle were observed.

CONCLUSION

The study showed a significant correlation between mandibular growth and skeletal maturity.

The effect of skeletal maturity on the regenerative function of intrinsic ACL cells

Anterior cruciate ligament (ACL) injuries are an important clinical problem, particularly for adolescent patients. The effect of skeletal maturity on the potential for ACL healing is as yet unknown. In this study, we hypothesized that fibroblastic cells from the ACLs of skeletally immature animals would proliferate and migrate more quickly than cells from adolescent and adult animals. ACL tissue from skeletally immature, adolescent, and adult pigs and sheep were obtained and cells obtained using explant culture. Cell proliferation within a collagen-platelet scaffold was measured at days 2, 7, and 14 of culture using AM MTT assay. Cellular migration was measured at 4 and 24 h using a modified Boyden chamber assay, and cell outgrowth from the explants also measured at 1 week. ACL cells from skeletally immature animals had higher proliferation between 7 and 14 days (p<0.01 for all comparisons) and higher migration potential at all time points in both species (p<0.01 for all comparisons). ACL cells from skeletally immature animals have greater cellular proliferation and migration potential than cells from adolescent or adult animals. These experiments suggest that skeletal maturity may influence the biologic repair capacity of intrinsic ACL cells.

Assessment of Growth Using Mandibular Canine Calcification Stages and Its Correlation with Modified MP3 Stages

BACKGROUND AND OBJECTIVES

Orthodontic diagnosis and treatment planning for growing children must involve growth prediction, especially in the treatment of skeletal problems. Studies have shown that a strong association exists between skeletal maturity and dental calcification stages. The present study was therefore taken up to provide a simple and practical method for assessing skeletal maturity using a dental periapical film and standard dental X-ray machine, to compare the developmental stages of the mandibular canine with that of developmental stages of modified MP3 and to find out if any correlation exists, to determine if the developmental stages of the mandibular canine alone can be used as a reliable indicator for assessment of skeletal maturity.

METHODS

A total of 160 periapical radiographs (80 males and 80 females), of the mandibular right canine and the MP3 region was taken and assessed according to the Dermirjian's stages of dental calcification and the modified MP3 stages.

RESULTS

The correlation between the developmental stages of MP3 and the mandibular right canine in male and female groups, is of high statistical significance (p = 0.001). The correlation coefficient between MP3 stages and developmental stages of mandibular canine and chronological age in male and females was found to be not significant.

CONCLUSIONS

The correlation between the mandibular canine calcification stages and MP3 stages was found to be significant. The developmental stages of the mandibular canine could be used very reliably as a sole indicator for assessment of skeletal maturity.

Dorsal arthrodesis in prepubertal New Zealand white rabbits followed to skeletal maturity: Effect on thoracic dimensions, spine growth and neural elements

BACKGROUND

Several studies have shown that severe spinal deformity and early arthrodesis can adversely affect the development of the spine and thorax by changing their shape and reducing their normal function. This article analyzes the consequences of posterior fusion on the growth of spine, thorax and neural elements in New Zealand white rabbits and compares with similar human data.

MATERIALS AND METHODS

The first section of the article analyzes the consequences of T1-T6 dorsal arthrodesis on the growth of the spine, sternum, thorax volume and neural elements in 12 prepubertal female New Zealand white rabbits, through a study of CT scans and histology specimens. The second part, evaluates thoracic dimensions in 21 children with spinal arthrodesis for treatment of deformity performed prior to nine years of age.

RESULTS

Dorsal arthrodesis in prepubertal rabbits changes thoracic growth patterns. In operated rabbits thoracic depth grows more slowly than thoracic width. The sternum as well as length of thoracic vertebral bodies in the spinal segment T1-T6 show reduced growth. Children undergoing spinal arthrodesis before nine years of age were noted to have shortened height, short trunk and disproportionate body habitus at skeletal maturity. Observed spine height and chest dimension values were reduced compared to the expected norms. The ratio between chest width and chest depth was below normal values.

CONCLUSIONS

The first part of the study shows that thoracic dorsal arthrodesis in prepubertal New Zealand white rabbit influences thoracic, spine growth and affects the shape of pseudo unipolar neurons of the dorsal root ganglia. The second part demonstrates that children treated before nine years of age have significantly reduced spine height and thoracic dimensions. The thorax becomes elliptical as chest depth grows less than chest width. Both experimental and clinical findings contribute to explain reduced chest growth and subsequent thoracic growth disturbance in patients treated with early arthrodesis.

Treatment of severe late-onset Perthes' disease with soft tissue release and articulated hip distraction: revisited at skeletal maturity

PURPOSE

Late-onset Perthes' disease is diagnosed after 9 years of age. Conservative treatment and conventional surgical techniques have limited ability to reduce the pressure in the joint or change the shape of the femoral head. We used a combination of soft tissue release and joint distraction with a hinged mono-lateral external fixator for these patients. Ten of our patients reached skeletal maturity and were evaluated.

METHODS

Clinical assessment included: Harris hip score, hip range-of-motion (ROM), limb length discrepancy, and the Oxford hip questionnaire for pain and function. Radiographic assessment included: Sharp transverse acetabular inclination, the uncoverage percentage, the epiphyseal index before surgery (modified Eyre-Brook), at frame removal, and, at last follow-up, the epiphyseal quotient (of Sjovall) and the Stulberg classification.

RESULTS

Our study included eight boys and two girls (mean age at surgery 12.3 years, range 9.4-15.1, mean age at last follow-up 18.1 years, range 15.2-22.8). The mean follow-up was 5.7 years (range 4.3-7.8). The mean Harris hip score was 86.3/100 (range 48.5-96); one patient had <85 points. The hip ROM was slightly limited in most patients, and seven patients had limb shortening between 1-4 cm. The mean Oxford hip questionnaire score was 17.4/60 (range 12-31). The mean Sharp transverse acetabular inclination of the affected side was 42 degrees (range 36-54) compared to 39 degrees for the unaffected side (P = 0.045). The mean uncoverage percentage was 37% (range 27-47) compared to 20% for the unaffected side (P = 0.017). The mean epiphyseal index was 0.71 (range 0.31-0.92) before surgery, 0.79 (range 0.50-0.93) at frame removal (P = 0.012), and 0.72 (range 0.51-0.89) at last follow-up (P = 0.646). The epiphyseal quotient for the eight unilateral cases was 0.72 (range 0.49-0.91), and the Stulberg classification was type III for three cases and type IV for seven.

CONCLUSION

Patient satisfaction for function and pain following the combined procedure was good. Radiographic parameters did not change significantly. This should be regarded as a salvage procedure.