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Applicability of the Modified Fels and Optimized Oxford Skeletal Maturity Estimation Systems to the Modern Pediatric
Ryan J Furdock1, Andy Kuo2, Kallie J Chen1
1Department of Orthopaedics; University Hospital Cleveland Medical Center.
Insights
The modified Fels knee skeletal maturity system (SMS) shows discrepancies in modern pediatric males and black females compared to historical data. The optimized Oxford hip SMS did not show significant differences, suggesting potential need for knee system updates.
Area of Science:
- Pediatric Radiology
- Skeletal Development Assessment
- Medical Imaging Analysis
Background:
- Established skeletal maturity systems (SMS) like Greulich and Pyle have limitations with diverse populations.
- Modified Fels knee and optimized Oxford hip SMS show promise but require validation in contemporary pediatric cohorts.
- Previous SMS performance was primarily assessed on historical, predominantly white, pediatric populations.
Purpose of the Study:
- To evaluate the applicability of modified Fels knee and optimized Oxford hip SMS in modern, racially diverse pediatric populations.
- To determine if modifications are necessary for these SMS before widespread clinical use in current children.
- To compare skeletal age estimations between modern cohorts and historical data for both knee and hip SMS.
Main Methods:
- Collection of knee and hip radiographs from white and black males and females aged 7-17 years (January 2015-September 2020).
- Random selection of 5 nonpathologic radiographs per age/joint from each group for evaluation using modified Fels knee and optimized Oxford hip SMS.
- Statistical comparison of mean chronological age versus estimated skeletal age between modern cohort and historical Bolton-Brush data, employing paired t tests or Wilcoxon signed-rank tests with Bonferroni correction.
Main Results:
- High inter- and intrarater reliability (≥0.7) for all modified Fels knee and optimized Oxford hip parameters.
- Modified Fels knee SMS indicated advanced skeletal age in modern white males (0.74 y), black males (0.69 y), and black females (0.4 y) compared to historical counterparts.
- No significant differences were observed for the optimized Oxford hip SMS between modern and historical cohorts, nor between racial groups for either SMS.
Conclusions:
- The modified Fels knee SMS demonstrates discrepancies in skeletal age estimation for modern white males, black males, and black females compared to historical data.
- The optimized Oxford hip SMS shows consistent performance across historical and modern pediatric populations, irrespective of race.
- Further research is warranted to assess the clinical implications of these skeletal age estimation discrepancies for the modified Fels knee SMS.
Background:
The recently developed modified Fels knee and optimized Oxford hip skeletal maturity systems (SMS) have demonstrated impressive performance compared with the Greulich and Pyle skeletal age atlas when applied to the same historical, mostly white, pediatric population. We sought to determine whether these 2 systems require modification before being used in modern children.
Methods:
We collected knee and hip radiographs between January 2015 and September 2020 from our electronic medical record from 4 groups of children: (1) white males, (2) black males, (3) white females, and (4) black females. Males between 9 and 17 years and females between 7 and 15 years were included. After reliability analyses, 5 nonpathologic radiographs for each age and joint were randomly selected from each group and evaluated with the appropriate SMS. The mean discrepancy between each group's chronological age at the time of radiograph and estimated skeletal age was compared between our modern cohort and the historical Bolton-Brush children. After normality testing, paired t tests or Wilcoxon signed-rank tests were performed, as appropriate. A Bonferroni correction was applied to address multiple testing.
Results:
Three hundred sixty modern radiographs were evaluated (180 knees and 180 hips). All 7 modified Fels knee parameters and all 5 optimized Oxford hip parameters had inter and intrarater reliability coefficients ≥0.7, indicating good to very good reliability. For the modified Fels knee SMS, white males (Δ0.74 y, P <0.001), black males (Δ0.69 y, P <0.001), and black females (Δ0.4 y, P =0.04) had advanced skeletal age compared with their historical counterparts of the same sex. No differences were found between historical and modern patients for the optimized Oxford hip SMS. No differences were found for either SMS comparing modern patients along racial lines ( P >0.05 for all).
Conclusions:
Discrepancies in skeletal age estimates made by the modified Fels knee SMS exist between modern pediatric white males, black males, and black females and their historic counterparts. No differences were found when using optimized Oxford hip SMS. Future studies should evaluate how these translate to clinical decision-making.
Level Of Evidence:
Level III; retrospective chart review.
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