Comparison of the three age estimation methods: which is more reliable for Turkish children?

Interdisiplinary and intraobserver reliability of the Greulich-Pyle method among Turkish children

OBJECTIVES

Greulich-Pyle (GP) is one of the most used method for bone age determination (BAD) in various orthopedic, pediatric, radiological, and forensic situations. We aimed to investigate the inter- and intra-observer reliability of the GP method between the most relevant disciplines and its applicability to the Turkish population.

METHODS

One-hundred and eighty (90 boys, 90 girls) patients with a chronological age younger than 18 (mean 9.33) were included. X-rays mixed by the blinded investigator were evaluated by two orthopedists, two radiologists, and two pediatric endocrinologists to determine skeletal age according to the GP atlas. A month later the process was repeated. As a statistical method, Paired t-test was used for comparison, an Intraclass Correlation Coefficients test was used for reliability and a 95 % confidence interval was determined. Results were classified according to Landis-Koch.

RESULTS

All results were consistent with chronological age (p<0.001), according to the investigators' evaluations compared with chronological age. At the initial evaluation, the interobserver reliability of the method was 0.999 (excellent); at the second evaluation, the interobserver reliability was 0.997 (excellent). The intra-observer reliability of the method was 'excellent' in all observers. When results were separately evaluated by gender, excellent intraobserver correlation and excellent correlation with chronological age were found among all researchers (>0.9). When X-rays were divided into three groups based on age ranges and evaluated, 'moderate' and 'good' correlations with chronological age were obtained during the peripubertal period.

CONCLUSIONS

The GP method used in skeletal age determination has excellent inter- and intra-observer reliability. During the peripubertal period, potential discrepancies in bone age assessments should be kept in mind. This method can be used safely and reproducibly by the relevant specialists.

The accuracy of Cameriere methods in Turkish children: chronological age estimation using developing teeth and carpals and epiphyses of the ulna and radius

The aim of the present study was to develop a specific formula by measuring the developing teeth, carpal bones, and epiphyses of the ulna and radius to determine the chronological age in Turkish children. The left developing permanent mandibular teeth were evaluated, and the number of teeth with closed apex was recorded. The distance between the inner sides of open apex/apices was measured by using the ImageJ program and divided by the tooth length. The sum of the normalized open apices was also calculated. The carpal area (Ca), covering the epiphyses of ulna and radius and the carpal bones, was measured on the X-rays of left hand. The areas of each carpal bone and epiphyses of the ulna and radius were measured, and these measurements were added together to obtain the bone area (Bo). The Bo/Ca ratio between the total area of carpal bones and the carpal area was calculated to normalize the measurements. The accuracy of the equations formulated by Cameriere was evaluated, and a new regression equation was developed accordingly. The new formula showed no statistically significant difference between the chronological and the estimated age for females, males, and total sample. The new formula, which hit the age with 72.80% accuracy, was more successful in predicting chronological age than other adjusted regression equations. The new regression model, created for the Turkish children by using both developing teeth and hand-wrist bones, was considerably successful in estimating the chronological age.

A comparative study of three bone age assessment methods on Chinese preschool-aged children

BACKGROUND

Bone age assessment (BAA) is an essential tool utilized in outpatient pediatric clinics. Three major BAA methods, Greulich-Pyle (GP), Tanner-Whitehouse 3 (TW3), and China 05 RUS-CHN (RUS-CHN), were applied to comprehensively compare bone age (BA) and chronological age (CA) in a Chinese sample of preschool children. This study was designed to determine the most reliable method.

METHODS

The BAA sample consisted of 207 females and 183 males aged 3-6 years from the Zhejiang Province in China. The radiographs were estimated according to the GP, TW3, and RUS-CHN methods by two pediatric radiologists. The data was analyzed statistically using boxplots, the Wilcoxon rank test, and Student's t-test to explore the difference (D) between BA and CA.

RESULTS

According to the distributions of D, the boxplots showed that the median D of the TW3 method was close to zero for both male and female subjects. The TW3 and RUS-CHN methods overestimated the age of both genders. The TW3 method had the highest correct classification rate for males but a similar rate for females. The GP method did not show any significant difference between the BA and CA when applied to 3-year-old males and 4-year-old females while the TW3 method showed similar results when applied to 6-year-old females. The RUS-CHN method showed the least consistent results among the three methods.

CONCLUSION

The TW3 method was superior to the GP and RUS-CHN methods but not reliable on its own. It should be noted that a precise age diagnosis for preschool children cannot be easily made if only one of the methods is utilized. Therefore, it is advantageous to combine multiple methods when assessing bone age.

Comparison of Bone Age Assessments by Gruelich-Pyle, Gilsanz-Ratib, and Tanner Whitehouse Methods in Healthy Indian Children

BACKGROUND

There are several methods of bone age (BA) assessment, which include Gruelich-Pyle (GP), Gilsanz-Ratib (GR), and Tanner Whitehouse-3 (TW-3) methods. Although GP atlas is the most widely used, there are concerns about its accuracy in children of different ethnicities, making the use of the TW-3 method an attractive option in Indian children.

OBJECTIVES

1) To assess the relationship of BA with chronological age (CA) as assessed by different methods (GP, GR, and TW-3) in healthy Indian children 2) To assess which of the three methods of BA assessment is more suitable in Indian children.

METHODOLOGY

X-rays of 851 children (438 boys and 413 girls, aged 2-16.5 years) were analyzed by four independent observers using three different methods of BA estimation (GP, GR, and TW-3). Mean BAs were converted to Z-scores. For purpose of deciding which method of BA was most suitable in our cohort, a test of proportions and root mean square (RMS) deviations were computed.

RESULTS

Using the test of proportions, the TW-3 method was most suitable overall (P < 0.05). TW-3 method was again most applicable in prepubertal boys (P < 0.05), in prepubertal girls (although not significant, P > 0.1), and pubertal girls (P < 0.05). However, in pubertal boys, the GR atlas method was most suitable (P < 0.05). The same results were obtained when root mean square (RMS) deviations were computed. Interestingly, BA was underestimated in Indian boys irrespective of the method used. In Indian girls, however, the BA was underestimated till the pubertal growth spurt, after which there was rapid advancement of BA.

CONCLUSIONS

Among the three methods (GP, GR, and TW-3), the BAs estimated by the TW-3 method were closest to CAs. Hence, it seems reasonable to recommend the use of the TW-3 method for BA estimation in the Indian population till an Indian standard bone age atlas is developed.

Age estimation from the biometric information of hand bones: Development of new formulas

INTRODUCTION

In the judicial context of the age estimation of living individuals, a new method was recently proposed, based on the collection of biometric information on hand bones radiographs. The aim of this study was to apply this method to a large French sample to provide new tools for age estimation MATERIALS AND METHODS: The study sample consisted of metacarpals and proximal phalanges measurements of 1003 individuals aged less than 21 years. This sample was divided into two subgroups 1-12 and 13-21 years as the age of 13 is a relevant legal threshold for most European countries. A quadratic discriminant analysis was performed to identify the group to which an individual was most likely to belong. Age estimation formulas were also constructed from linear models: for each subgroup and the total sample.

RESULTS

The belonging of an individual to the 1-12 or 13-21 subgroup was determined with a correct classification rate of 89.8%. Age estimation formulas became less precise with age, with a mean absolute error ranging between 11 and 21 months.

CONCLUSION

We proposed a two-step procedure for age estimation: firstly, the identification of the age group to which the individual is most likely to belong, and secondly, the age estimation of this individual by applying the appropriate formula.

Applicability of two commonly used bone age assessment methods to twenty-first century UK children

Objectives

To assess the effect of secular change on skeletal maturation and thus on the applicability of the Greulich and Pyle (G&P) and Tanner and Whitehouse (TW3) methods.

Methods

BoneXpert was used to assess bone age from 392 hand trauma radiographs (206 males, 257 left). The paired sample t test was performed to assess the difference between mean bone age (BA) and mean chronological age (CA). ANOVA was used to assess the differences between groups based on socioeconomic status (taken from the Index of Multiple Deprivation).

Results

CA ranged from 2 to 15 years for females and 2.5 to 15 years for males. Numbers of children living in low, average and high socioeconomic areas were 216 (55%), 74 (19%) and 102 (26%) respectively. We found no statistically significant difference between BA and CA when using G&P. However, using TW3, CA was underestimated in females beyond the age of 3 years, with significant differences between BA and CA (− 0.43 years, SD 1.05, p = < 0.001) but not in males (0.01 years, SD 0.97, p = 0.76). Of the difference in females, 17.8% was accounted for by socioeconomic status.

Conclusion

No significant difference exists between BoneXpert-derived BA and CA when using the G&P atlas in our study population. There was a statistically significant underestimation of BoneXpert-derived BA compared with CA in females when using TW3, particularly in those from low and average socioeconomic backgrounds. Secular change has not led to significant advancement in skeletal maturation within our study population.

Key Points

• The Greulich and Pyle method can be applied to the present-day United Kingdom (UK) population.

• The Tanner and Whitehouse (TW3) method consistently underestimates the age of twenty-first century UK females by an average of 5 months.

• Secular change has not advanced skeletal maturity of present-day UK children compared with those of the mid-twentieth century.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06300-x) contains supplementary material, which is available to authorized users.

Is the Greulich and Pyle atlas applicable to all ethnicities? A systematic review and meta-analysis

OBJECTIVE

To determine whether the Greulich and Pyle (G&P) atlas is applicable when applied to populations of different ethnicity.

METHODS

A systematic review of studies published between 1959 and 15th February 2017 identified from the Embase, MEDLINE and Cochrane databases was undertaken. Quality of the studies was assessed using the National Institute for Health and Care Excellence tool. Meta-analysis used mean differences and standard deviations as summary statistics for the difference between bone age (BA) and chronological age (CA).

RESULTS

A total of 49 studies were included of which 27 (55%) were related to Caucasian populations. Of the 49 eligible studies, 35 were appropriate for further meta-analysis. In African females, meta-analysis showed a significant mean difference between BA and CA of 0.37 years (95% CI 0.04, 0.69). In Asian males, meta-analysis showed significant differences between BA and CA of -1.08, -1.35, -1.07, -0.80 and 0.50 years for chronological ages of 6, 7, 8, 9 and 17 years, respectively. Meta-analysis showed no significant differences between BA and CA in African males, Asian females, Caucasians and Hispanics.

CONCLUSIONS

The G&P standard is imprecise and should be used with caution when applied to Asian male and African female populations, particularly when aiming to determine chronological age for forensic/legal purposes.

KEY POINTS

• In African females, bone age is significantly advanced when compared to the G&P standard. • In Asian males, bone age is significantly delayed between 6 and 9 years old inclusive and significantly advanced at 17 years old when compared to the G&P standard. • The G&P atlas should be used with caution when applied to Asian and African populations, particularly when aiming to determine chronological age for forensic/legal purposes.

DNA methylation markers in combination with skeletal and dental ages to improve age estimation in children

Age estimation is critical in forensic science, in competitive sports and games and in other age-related fields, but the current methods are suboptimal. The combination of age-associated DNA methylation markers with skeletal age (SA) and dental age (DA) may improve the accuracy and precision of age estimation, but no study has examined this topic. In the current study, we measured SA (GP, TW3-RUS, and TW3-Carpal methods) and DA (Demirjian and Willems methods) by X-ray examination in 124 Chinese children (78 boys and 46 girls) aged 6-15 years. To identify age-associated CpG sites, we analyzed methylome-wide DNA methylation profiling by using the Illumina HumanMethylation450 BeadChip system in 48 randomly selected children. Five CpG sites were identified as associated with chronologic age (CA), with an absolute value of Pearson's correlation coefficient (r)>0.5 (p<0.01) and a false discovery rate<0.01. The validation of age-associated CpG sites was performed using droplet digital PCR techniques in all 124 children. After validation, four CpG sites for boys and five CpG sites for girls were further adopted to build the age estimation model with SA and DA using multivariate linear stepwise regressions. These CpG sites were located at 4 known genes: DDO, PRPH2, DHX8, and ITGA2B and at one unknown gene with the Illumina ID number of 22398226. The accuracy of age estimation methods was compared according to the mean absolute error (MAE) and root mean square error (RMSE). The best single measure for SA was the TW3-RUS method (MAE=0.69years, RMSE=0.95years) in boys, and the GP method (MAE=0.74years, RMSE=0.94years) in girls. For DA, the Willems method was the best single measure for both boys (MAE=0.63years, RMSE=0.78years) and girls (MAE=0.54years, RMSE=0.68years). The models that incorporated SA and DA with the methylation levels of age-associated CpG sites provided the highest accuracy of age estimation in both boys (MAE=0.47years, R²=0.886) and girls (MAE=0.33years, R²=0.941). Cross validation of the results confirmed the reliability and validity of the models. In conclusion, age-associated DNA methylation markers in combination with SA and DA greatly improve the accuracy of age estimation in Chinese children. This method may be applied in forensic science, in competitive sports and games and in other age-related fields.

Evaluation of the ossification of the medial clavicle according to the Kellinghaus substage system in identifying the 18-year-old age limit in the estimation of forensic age-is it necessary?

The evaluation of the ossification of the medial clavicular epiphysis being part of an assigned expert approach according to standard plays an important role within civil and criminal proceedings in assessing whether a person has reached her/his 19th or 22nd year of age. Evaluation of the medial clavicular epiphysis with thin-section CT is one of the methods recommended by the Study Group on Forensic Age Diagnostics of the German Association of Forensic Medicine. In this retrospective study, we evaluated the thin-section CT (section thickness of 0.6 and 1 mm) images of 254 patients (146 male, 108 female) with an age range of 13-28 years according to the Kellinghaus substage system. The mean values of female patients were observed to be about 10 months lower for stage 2a than the mean values of the male patients, about 13 months lower for stage 2b, and about 18 months lower for stage 2c. The earliest appearance for stage 3c was at 19 years in both sexes. Our data from this study were consistent with both our previous studies and the data of other studies. We think that stage 3c is important in determining whether a person has reached the age of 18 or not and, therefore, that the Kellinghaus substage system is a requirement in the assessment of forensic age.

Is Greulich and Pyle standards of skeletal maturation applicable for age estimation in South Indian Andhra children?

Introduction:

Now-a-day age determination has gained importance for various forensic and legal reasons. Skeletal age (SA) of a test population can be estimated by comparing with established standards of Greulich and Pyle (G-P). As this atlas has been prepared using data from upper-class children born between 1917 and 1942 in the USA and the applicability of these standards to contemporary populations has yet to be tested on Andhra children living in India. Hence, this study was aimed to assess the reliability of bone age calculated by G-P atlas in estimation of age in selected population.

Materials and Methods:

A total of 660 children (330 girls, 330 boys) between ages 9 and 20 years were randomly selected from outpatient Department of Oral Medicine in GITAM Dental College, Andhra Pradesh. Digital hand-wrist radiographs were obtained and assessed for SA using G-P atlas and the difference between estimated SA and chronological age (CA) were compared with paired t-test and Wilcoxon signed rank test.

Results:

G-P method underestimated the SA by 0.23 ± 1.53 years for boys and overestimated SA by 0.02 ± 2 years in girls and mild underestimation was noted in the total sample of about 0.1 ± 1.78 years. Spearman rank test showed significant correlation between SA and CA (r = 0.86; P < 0.001).

Conclusion:

This study concluded that G-P standards were reliable in assessing age in South Indian Andhra children of age 9–20 years with unknown CA.

Can the Greulich and Pyle method be used on French contemporary individuals?

Forensic age estimation of living individuals has become increasingly important in forensic practice with the constant increase of migration movements to developed countries. The method of Greulich and Pyle is one of the most frequently used methods for age determination. The aim of our study was to verify the reliability of this method on a French contemporary population. We retrospectively analyzed 190 frontal hand and wrist radiographs of living subjects aged between 10 and 19 years (100 males and 90 females) performed in the Radiology Department of the University Hospital of Tours. These radiographs were compared with the Greulich and Pyle atlas to determine the skeletal age (SA) and to compare it to the chronological age (CA). We calculated the coefficient of correlation and the coefficient of determination for each sex group. The SA of our subjects was also inserted in the graphs provided by Greulich and Pyle in their atlas. Intra- and inter-observer variabilities were good, demonstrating the reproducibility and repeatability of the method. The correlation coefficients were high (0.98 for males and 0.93 for females) and comparable with published data. The mean difference between CA and SA was -2.29 months for males and -6.44 months for females, showing an overestimation of CA for both sexes. No statistical difference was found between CA and SA for both male and female samples. We concluded that the method of Greulich and Pyle can be used on a contemporary French population but not without caution because of a tendency for this method to overestimate age. A fully developed hand and wrist does not allow to state that the 18th year of life is completed beyond a reasonable doubt. We recommend using it in association with other methods.

The utility of the proximal epiphysis of the fifth metatarsal in age estimation

Radiographs of 277 living individuals were assessed via a numerical scoring system to determine the timing of appearance and degree of fusion between the proximal epiphysis of the fifth metatarsal and its diaphysis. The epiphysis was observed to first appear in females at 8 years and 10 years in males and fuse by 14 years in females and 15 years in males. When assessing the level of agreement of category assignment, inter-observer agreement was 78% for females and 64% for males whereas intra-observer agreement was 77% for females and 86.1% for males. These results suggest that the maturation of the proximal epiphysis of the fifth metatarsal may be of value in age estimation in the child and that the scoring system is sufficiently robust to merit continued investigation. Previously this epiphysis has been considered an inconstant feature, but this research confirmed its presence in all individuals studied.

Longitudinal comparison of skeletal age determined by the Greulich and Pyle method and chronologic age in normally growing children, and clinical interpretations for orthodontics

INTRODUCTION

Coinciding treatment with periods of accelerated skeletal growth and maturation might be advantageous in clinical practice. Better understanding of the concordance between skeletal and chronologic ages during the period that children frequently receive orthodontic treatment is needed. The literature on skeletal age determination from hand-wrist radiographs lacks reports based on longitudinal data, creating lacunae in the understanding of the magnitudes and variations of differences between skeletal and chronologic ages. The aims of this research were to comprehensively analyze the concordance between skeletal and chronologic ages determined by using the Greulich and Pyle method at different ages in the preadolescent and adolescent periods, and to determine any age- and sex-related differences in the concordance.

METHODS

By using the Greulich and Pyle method, skeletal age determinations were made from 572 hand-wrist radiographs of 68 white children with normal facial growth, selected from the records of the Burlington Growth Centre, spanning the growth period from 9 to 18 years. Skeletal age and chronologic age differences for each sex were analyzed by using paired t tests and Wilcoxon signed rank tests at yearly intervals. Differences over the longitudinal duration were examined by using the mixed model approach. The limits of agreement were determined by using the Bland-Altman method. In each yearly chronologic age group, differences were clinically categorized based on the proximity of the skeletal and chronologic ages.

RESULTS

Overall, a slightly greater proportion of the total skeletal age determinations made in girls (41.9%) were within 0.5 year of their chronologic age, compared with 38% in boys. The largest proportions of subjects having skeletal age-chronologic age differences within 0.5 year were in the 10-year age group in girls (64.5%) and the 13-year age group in boys (64.7%). Mean skeletal age-chronologic age differences were significantly larger in the 13- to 16-year age groups in girls and in the 16- and 17-year age groups in boys, but the differences were not statistically significant at other ages. Several patterns of variations were identified in the direction of differences when individual plots were examined.

CONCLUSIONS

This longitudinal analysis of differences between skeletal and chronologic ages showed wide ranges and distributions of differences at each yearly age group during the growth period from 9 to 18 years, even when mean differences were small. Variations in the magnitude and direction of differences observed at different ages highlighted the variability in skeletal maturation among normally growing young people. Overall, the differences in skeletal and chronologic ages were positively related to age, with little effect of sex or its interaction with age.

The reliability of the Greulich and Pyle atlas when applied to a modern Scottish population

This study examines the reliability of age estimation utilizing the Greulich and Pyle atlas in relation to a modern Scottish population. A total of 406 left-hand/wrist radiographs (157 females and 249 males) were age-assessed using the Greulich and Pyle atlas. Analysis showed that there was a strong correlation between chronological age and estimated age (females R(2) = 0.939, males R(2) = 0.940). When age groups were broken down into year cohorts, the atlas over-aged females from birth until 13 years of age. The pattern for males showed that the atlas under-estimated age until 13 years of age after which point it consistently over-aged boys between 13 and 17 years of age. This study showed that the Greulich and Pyle atlas can be applied to a modern population but would recommend that any analysis takes into account the potential for over- and under-aging shown in this study.

Accuracy of three age determination X-ray methods on the left hand-wrist: a systematic review and meta-analysis

Age estimation of living individuals often represents a forensic challenge with important legal and social implications. In an effort to better understand the accuracy of the methods of Greulich and Pyle (GP), Tanner-Whitehouse (TW) and Fels, a systematic review and a meta-analysis of articles published from 1956 to 20 December 2009 in the Medline and Trip databases were conducted. We only selected articles on healthy people. The meta-analysis showed that GP is not as accurate a method as TW2 or TW3 for both Caucasian people and Mongoloids, even if it is the one most often used. However, due to the very wide age estimation range, in line with what has already been established by several authors, our systematic review and meta-analysis confirmed that age estimation in living individuals cannot be considered accurate when only X-ray methods on the left hand-wrist are used, but exhaustive combinations of various procedures (i.e. physical examination, dental and skeletal methods) must also be used, as proposed and already applied by the International Study Group on Forensic Age Estimation.