Bone age assessment based on different MRI modalities of the proximal humerus epiphysis: the comparisons of T1WI, T2WI, and PDWI.

Bone age assessment (BAA) is crucial in various fields, including legal proceedings, athletic competitions, and clinical medicine. However, the use of X-ray methods for age estimation without medical indication is subject to ethical debate, especially in forensic and athletic fields. The application of magnetic resonance imaging (MRI) with non-ionizing radiation can overcome this limitation in BAA. This study aimed to compare the application value of several MRI modalities of proximal humeral in BAA. A total of 468 patients with shoulder MRIs were retrospectively collected from a Chinese Han population aged 12-30 years (259 males and 209 females) for training and testing, including T1 weighted MRI (T1WI), T2 weighted MRI (T2WI), and Proton density weighted MRI (PDWI). Optimal regression models were established for age estimation, yielding mean absolute error (MAE) values below 2.0 years. The MAE values of T1WI were the lowest, with 1.700 years in males and 1.798 years in females. The area under the curve (AUC) and accuracy values of different MRI modalities of 16-year and 18-year thresholds were all around 0.9. For the 18-year threshold, T1WI outperformed T2WI and PDWI. In conclusion, the three MRI modalities of the proximal humerus can serve as reliable indicators for age assessment, while the T1WI performed better in age assessment and classification.

Ultrasonographic assessment of ossification of the distal radial epiphysis for estimating forensic age.

Since forensic age estimation is not a valid medical indication, research on the use of nonionizing methods is increasing. Ultrasonography is a radiological approach that protects patients from radiation exposure and offers special convenience to them. In this study, ultrasonography was used for age estimation by investigating the degree of ossification of the distal radial epiphysis. Its applicability on the Turkish population was investigated. The left wrist of 688 (322 males, 366 females) patients between the ages of 9 and 25 years was prospectively evaluated by ultrasonography. The intra- and interobserver reliabilities in evaluating the distal radial epiphysis and Cohen's kappa statistics show that the interobserver error was very low, and the kappa value was found to be 0.919. Stage 3 and 4 ossification of the distal radial epiphysis was first detected at age 14.3 and 15.3 years in males and 12.7 and 14.8 years in females, respectively. The data obtained may help determine legally critical age limits of 14 and 15. Although it does not seem useful for the age of 18, ultrasonography may be recommended in selected cases as a fast, inexpensive, frequently reproducible radiological method without concern about radiation and without a predictable health risk.

CT of the medial clavicular epiphysis for forensic age estimation: hands up?

PURPOSE: The aim of this study was to assess the impact of arm position in computed tomography (CT) of the clavicle performed for forensic age estimation on clavicular position, image noise, and radiation dose. METHODS AND MATERIALS: Forty-seven CT scans of the medial clavicular epiphysis performed for forensic age estimation were conducted with either hands and arms held upwards (CTHU, 28 persons) or positioned at the body (CTHD, 19 persons). Presets were identical for both positions (70 mAs/140 kVp; Brilliance iCT, Philips). Each CT scan was reconstructed with an iterative algorithm (i-Dose 4) and evaluated at the middle of the sternoclavicular joint. Clavicular angle was measured on a.p. topograms in relation to a horizontal line. Quantitative image noise was measured in air at the level of medial clavicular epiphysis. Effective dose and scan length were recorded. RESULTS: Hands-up position compared with hands-down position resulted in a lower lateral body diameter (CTHU 41.1 ± 3.6 cm vs. CTHD 44.6 ± 3.1 cm; P = 0.03), a reduced quantitative image noise (CTHU: 39.5 ± 9.2; CTHD: 46.2 ± 8.3; P = 0.02), and lower CTDIvol (5.1 ± 1.4 mGy vs. 6.7 ± 1.8 mGy; P = 0.001). Scan length was longer in patients examined with hands up (HU: 8.5 ± 3.4 cm; HD: 6.2 ± 2.1 cm; P = 0.006). Mean effective dose for CTHU was 0.79 ± 0.32 mSv compared with 0.95 ± 0.38 mSv in CTHD (P = 0.12). Clavicular angle was 17° ± 6° in patients with hands down and 32° ± 7° in patients with hands up (P < 0.001). CONCLUSION: By elevated arm positioning, the image quality of clavicular CT scans can be improved while maintaining radiation dose compared with hands down. Clavicular position differs according to the hand position. Thus, positioning patients with elevated hands is advisable for forensic clavicular CT examinations, but multiplanar CT reconstructions should be adjusted to clavicular position and scan length should be reduced to a minimum.

Forensic age estimation via magnetic resonance imaging of knee in the Turkish population: use of T1-TSE sequence.

The evaluation of epiphyseal areas by magnetic resonance imaging (MRI) for forensic age estimation is an important supportive diagnostic method to prevent repeated radiation exposure without a valid medical reason. There are still not enough individuals being analyzed with MRI for age estimation. The aim of this study was to investigate the utility of T1-weighted turbo spin echo (T1-TSE) MRI sequences in determining the degree of ossification of the distal femoral and proximal tibial epiphyses in a Turkish population. In this study, images from 649 patients (335 males and 314 females) aged 10-30 years were retrospectively evaluated with sagittal T1-weighted turbo spin echo (T1-TSE) MRI sequences of the knee. Proximal tibial and distal femoral epiphysis were scored by two different observers twice using the combined staging system described by Schmeling and Kellinghaus. Spearman's rank correlation analysis indicated a significant positive relationship between age and ossification stages of the distal femoral and proximal tibial epiphyses (p < 0.001). The intra- and inter-observer reliabilities in evaluating the femur and tibia were separately determined and gave promising results and Cohen's kappa statistics ranged from κ = 0.886 and κ = 0.961. The minimal ages of patients with stage 4 ossification were 15.1 years for females and 15.8 years for males for the distal tibial epiphysis and 15.4 years for females and 17 years for males for the distal femoral epiphysis. This study show that (T1-TSE) MRI and the applicability and Schmeling and Kellinghaus staging method of the knee can be performed for living 14- to 17-year-old individuals in need of a supportive noninvasive method for estimating forensic age.

Evaluation of the Ossification Stage of Proximal Humeral Epiphysis by 1.5-T Magnetic Resonance Imaging for Determination of Skeletal Age.

PURPOSE: The aim of the study was to investigate whether the skeletal age can be evaluated assessed by means of analysis of ossification stage at proximal humeral epiphysis using magnetic resonance imaging (MRI). METHODS: This retrospective study was carried out in the radiology department of a tertiary healthcare center and 1.5-T MRI views of the shoulder obtained from 203 patients aged 8 to 29 years were evaluated. The ossification stage of proximal humeral epiphysis was evaluated on T1-weighted MRI sequences, and its correlation with age was sought. RESULTS: Our series consisted of 77 women (37.9%) and 126 men (62.1%). One hundred forty-seven right humerus (72.4%) and 56 (27.6%) left humerus were examined. The mean age of the patients was 20.60 ± 4.41 years. The patients were in stages 4 (n = 148, 72.9%), 3c (n = 18, 8.9%), 3b (n = 14, 6.9%), 2c (n = 13, 6.4%), and 3a (n = 10, 4.9%). Analysis of the relationship between age and ossification stage of proximal humerus epiphysis indicated that stage increased with the advancement of age. There was a significant correlation between the stage and age variables at a rate of 77% in the positive direction (P < 0.001). CONCLUSIONS: Our results demonstrated that MRI of proximal humeral epiphysis can have valuable implications for estimation of the skeletal age. Future prospective studies must be implemented with patients grouped according to socioeconomic status, nutritional habits, and physical activities to explore the actual investigative potential of MRI.

Applicability of Magnetic Resonance Imaging of the Knee in Forensic Age Estimation.

ABSTRACT: Age estimation in forensic medicine practice is of particular importance to the legal systems, and it is one of the current research topics in forensic medicine. Age determination is most frequently performed by radiological methods, but recently, nonionized methods are preferred for nonmedical indications. Therefore, we aimed to examine feasibility of MRI imaging, which provides nonionized, noninvasive, and detailed images, in forensic age estimation and to expand the database on this subject. The MRI images of the patients between the ages of 10 and 25 years, who visited Cukurova University Faculty of Medicine between January 2012 and April 2018 for any reason, were retrospectively analyzed according to the staging method described by Dedouit et al. The stage 5 ossification in distal femoral epiphysis indicated an age over 18 years in both sexes (except for 2 cases of 14 and 15 years). The stage 5 ossification in proximal tibial epiphysis indicated an age older than 18 years (except for 1 male case at the age of 15 years and 2 female cases at the age of 14 and 17 years, respectively). It was determined that stage 1 and stage 2 in both distal femur and proximal tibial epiphysis were last seen in younger than 18 years in both sexes. Our study data show that MRI imaging is a nonionized method that can be used in addition to other radiological methods in determining the age limit of 18 years.

Age estimation based on magnetic resonance imaging of the ankle joint in a modern Chinese Han population.

OBJECTIVES: To expand the database on magnetic resonance imaging (MRI) analysis of distal tibial and calcaneal epiphyses as proposed by Saint-Martin et al. and investigate a more elaborate staging technique to establish regression models for age estimation in a modern Chinese Han population. MATERIALS AND METHODS: T1-weighted ankle MRIs were retrospectively collected from April 2008 to July 2019, and data from 590 individuals (372 males and 218 females; aged from 8 to 25 years old) were obtained. One-sided sagittal images were assessed because data from both sides were considered coincidental, as no significant differences were found (P > 0.05). Three-stage and six-stage staging techniques were applied separately and subsequently compared. A subset was re-assessed a second time and by a different observer. Regression models were established accordingly. RESULTS: Our results showed very good repeatability and consistency of two staging techniques (all Cohen's kappa values were more than 0.8). By comparison, the values of the coefficient of determination (R2) of the six-stage technique were generally higher than those of the three-stage technique. Compared with the distal tibia and two ankle bones combined, the calcaneus decreased the mean absolute deviation (MAD) with the six-stage technique. In males, incorporating only the calcaneus resulted in a MAD of 2.15 years, with correct classification rates of 87.5% adults and 50.0% among minors. In females, the corresponding results were 1.67 years, 100.0%, and 44.4%, respectively. CONCLUSIONS: The six-stage technique may outperform the three-stage technique in MRI analysis of ankle bones for age estimation, while age estimation based on the calcaneus may perform better than that based on the distal tibia or both ankle bones in a modern Chinese Han population.

Predicting Growth Quantitatively Through Proximal Tibia Radiograph Markers.

BACKGROUND: The creation of accurate markers for skeletal maturity has been of significant interest to orthopaedic surgeons. They guide the management of diverse disorders such as adolescent idiopathic scoliosis, leg length discrepancy, cruciate ligament injuries, and slipped capital femoral epiphysis. Multiple systems have been described to predict growth using radiographic skeletal markers; however, no such system has yet been developed for the proximal tibia. The purpose of this study was to establish quantitative radiographic parameters within the proximal tibia that can be used to assess degree of skeletal maturity. METHODS: From the Bolton Brush collection, 94 children, consisting of 49 girls and 4 boys between the ages of 3 and 18 years old, were followed annually throughout growth with serial radiographs and physical examinations. Final height at maturity was used to calculate the growth remaining at each visit. Multiple measurements for each knee radiograph were performed and correlated with the percentage of growth remaining. Tibial epiphysis width, tibial metaphysis width, and height of the lateral tibial epiphysis were measured on each film and the composite ratios between each of these sets of variables along with their respective accuracy and reliability were calculated. Single and multiple linear regression models were constructed to determine accuracy of prediction. Interobserver and intraobserver studies were performed with 4 investigators ranging from medical student to senior attending and calculated using the intraclass correlation coefficient. All 4 examiners measured all of the subjects and the ratios created were averaged. RESULTS: Tibial epiphysis width, tibial metaphysis width, and height of the lateral tibial epiphysis were all found to be strongly correlated with growth remaining with R values ranging from 0.57 to 0.84. In addition, all 3 ratios were found to be reliable with intraobserver and interobserver intraclass correlation coefficients ranging from 0.92 to 0.94 and 0.80 to 0.94, respectively. A multiple linear regression model demonstrated that combining these 3 ratios allows for a predictive R value of 0.917, showing that these ratios when combined were highly predictive of growth remaining. All findings were independent of sex (P=0.996). CONCLUSIONS: We describe 3 measurements that can easily be obtained on an anteroposterior radiograph of the knee. We demonstrate that ratios of these variables can be measured reliably and correlate closely with remaining growth, independent of sex. Together, we believe that these factors will improve the accuracy of determining growth from lower extremity radiographs that include the proximal tibia. CLINICAL RELEVANCE: This study provides a new quantitative technique to evaluate growth in the lower extremity, which can inform a range of conditions including adolescent idiopathic scoliosis, leg length discrepancy, cruciate ligament injury, and slipped capital femoral epiphyses.

Patellar-Trochlear Morphology in Pediatric Patients From 2 to 11 Years of Age: A Descriptive Analysis Based on Computed Tomography Scanning.

BACKGROUND: Despite the critical role the trochlea plays in patellofemoral (PF) pathology, the development of the trochlea is poorly understood. The purpose of this study was 2-fold: (1) Describe quantitative osseous and soft tissue anatomy of the patella and trochlea in skeletally immature cadaveric specimens utilizing known measurements used in PF instability, and (2) evaluate additional measurement techniques in the sagittal plane as they relate to PF morphologic development. METHODS: Thirty-one skeletally immature fresh frozen cadaveric knees between the ages of 2 and 11 years old were evaluated using 0.625 mm computed tomography scans. In the axial plane, measurements included condylar height asymmetry, trochlear facet asymmetry, trochlear depth, osseous sulcus angle, cartilaginous sulcus angle, patella sulcus angle, and tibial tubercle-trochlear groove distance. In the sagittal plane, measurements included previously undescribed measurements of trochlear length and condylar height asymmetry which are based on the anterior femoral cortex. RESULTS: Analysis of trochlear morphology using condylar height asymmetry (both axial and sagittal), trochlear facet asymmetry, and trochlear depth and length demonstrated an increase in the size of the medial and lateral trochlea as age increased. There was more variability in the change of size of the medial trochlea (height, length, and facet length) than the lateral trochlea. The osseous sulcus angle, cartilaginous sulcus angle, and patella sulcus angle decreased (became deeper) with age until after 8 years and then plateaued. CONCLUSIONS: This cadaveric analysis demonstrated that there is an increase in the medial and lateral trochlear height as age increased by all measurements analyzed. The findings also demonstrate that the shape of the patella and trochlea change concurrently, which suggests that there may be interplay between the 2 during development. These new sagittal measurement techniques evaluating the medial, central, and lateral trochlear height and length with respect to age may help guide clinicians when investigating patellar instability in skeletally immature patients. LEVELS OF EVIDENCE: Level IV.

Technical note: utilization of 3D-rendering for CT evaluation of extremitas sternalis claviculae within medical age assessment practice.

According to the acknowledged recommendations of the multidisciplinary "Study Group on Forensic Age Diagnostics," the indicator "medial clavicular ossification" carries the potential of delivering decisive evidence to proof age majority "beyond reasonable doubt" regarding age-disputed individuals within legal procedures. Yet, sternoclavicular thin-slice computed tomography, representing its preferred imaging modality, not rarely exhibits peculiar morphologies of the site, sometimes difficult to understand from the usually obtained, axial sections together with coronal reformations. Because of that, we utilized 3D-rendering of acquired CT data in 224 cases with the purpose to gain additional visualization of certain questionable appearances. Concerning reliable classification of medial clavicular ossification in line with the typologies of Schmeling et al. and Kellinghaus et al., it is concluded that such means of illustration contribute to recognition of polygonal or irregular, epiphyseal formations including the not-assessable shape variant "multiple, medial, secondary ossification centres" and of calcification of the articular capsule.

Applicability of T1-weighted MRI in the assessment of forensic age based on the epiphyseal closure of the humeral head.

This work investigates the value of magnetic resonance imaging analysis of proximal epiphyseal fusion in research examining the growth and development of the humerus and its potential utility in establishing forensic age estimation. In this study, 428 proximal humeral epiphyses (patient age, 12-30 years) were evaluated with T1-weighted turbo spin echo (T1 TSE) sequences in coronal oblique orientation on shoulder MRI images. A scoring system was created following a combination of the Schmeling and Kellinghaus methods. Spearman's rank correlation analysis revealed a significant positive relationship between age and ossification stage of the proximal humeral epiphysis (all subjects: rho = 0.664, p < 0.001; males: 0.631, p < 0.001; females: rho = 0.651, p < 0.001). The intra- and inter-observer reliability assessed using Cohen's kappa statistic was κ = 0.898 and κ = 0.828, respectively. The earliest age of epiphysis closure was 17 years for females and 18 years for males. MRI of the proximal humeral epiphysis can be considered advantageous for forensic age estimation of living individuals in a variety of situations, ranging from monitoring public health to estimating the age of illegal immigrants/asylum seekers, minors engaged in criminal activities, and illegal participants in competitive sports, without the danger of radiation exposure.

Forensic age diagnostics by magnetic resonance imaging of the proximal humeral epiphysis.

The most commonly used radiological method for age estimation of living individuals is X-ray. Computed tomography is not commonly used due to high radiation exposure, which raises ethical concerns. This problem can be solved with the use of magnetic resonance imaging (MRI), which avoids the use of ionizing radiation. The purpose of the present study was to evaluate the utility of MRI analysis of the proximal humeral epiphyses for forensic age estimations of living individuals. In this study, 395 left proximal humeral epiphyses (patient age 12-30 years) were evaluated with fast-spin-echo proton density-weighted image (FSE PD) sequences in a coronal oblique orientation on shoulder MRI images. A five-stage scoring system was used following the method of Dedouit et al. The intra- and interobserver reliabilities assessed using Cohen's kappa statistic were κ = 0.818 and κ = 0.798, respectively. According to this study, stage five first appeared at 20 and 21 years of age in males and females, respectively. These results are not directly comparable to any other published study due to the lack of MRI data on proximal humeral head development. These findings may provide valuable information for legally important age thresholds using shoulder MRI. The current study demonstrates that MRI of the proximal humerus can support forensic age estimation. Further research is needed to establish a standardized protocol that can be applied worldwide.

Anatomic shape variants of extremitas sternalis claviculae as collected from sternoclavicular thin-slice CT-studies of 2820 male borderline-adults.

Within medical age assessment practice, the indicator "medial clavicular ossification" constitutes crucial evidence capable of excluding age minority "beyond reasonable doubt" concerning age-disputed individuals doubtfully claiming children's rights during legal procedures. Yet, one of its characteristics affects the morphological variability including a fair amount of downright peculiar appearances. As a result, inexperienced examiners are tempted to classify actually not-assessable formations according to the two established developmental typologies of Schmeling et al. and Kellinghaus et al. being at the same time the most frequent systemic error of age-related clavicular taxation. Since a respective overview appears missing, the study extracts not-assessable shape variants of the medial collar bone from a large sample of 2820 male borderline-adults as seen from thin-slice, sternoclavicular computed tomography. The two already highlighted configurations "more than one, medial, secondary ossification centres" and "medial metaphyseal concavity" are found as the most commonly encountered features impeding reliable delineation of staging criteria. In accordance with previous literature, it is emphasized that "qualified" rating of extremitas sternalis claviculae within age assessment practice presupposes "knowledge about the diversity of [its] anatomic shape variants."

Carpals and epiphyses of radius and ulna as age indicators using longitudinal data: a Bayesian approach.

The aim of this study is to develop a new formula for age estimation in a longitudinal study of a sample from the radiological collection of wrist bones of growing infants, children, and adolescents recorded at the Burlington Growth Centre. A sample of 82 individuals (43 boys and 39 girls), aged between 3 and 16 years, were analyzed with a total of 623 X-rays of left hand-wrist bones by measuring the area of carpal bones and epiphyses of the ulna and radius (Bo) and carpal area (Ca). The intra-class correlation coefficient (ICC) and its 95% confidence interval were used to evaluate intra-observer agreement. Hierarchical Bayesian calibration has been adopted to exceed the bias deriving from the classical regression approach used for age estimation in forensic disciplines, since it tends to overestimate or underestimate the age of the individuals. Calibration distributions of the dataset obtained by the evaluation of BoCa (the ratio of Bo and Ca) suggested mean absolute errors (MAE) of 1.07 and 1.34 years in boys and girls, respectively. The mean interquartile range (MIQR) was 1.7 and 2.42 years in boys and girls, respectively. The respective bias of the estimates was ßERR = - 0.025 and - 0.074. Furthermore, a correspondence between different BoCa values and estimated age with its standard deviation (SD) was calculated for boys and girls, respectively. In conclusion, the Bayesian calibration method appears to be suitable for assessing both age and its distribution in subadults, according to hand-wrist maturity. Furthermore, it can easily incorporate other age predictors, obtaining a distribution of the subjects with multivariate predictors.

Error rates for unvalidated medical age assessment procedures.

During 2014-2015, Sweden received asylum applications from more than 240,000 people, of which more than 40,000 were termed unaccompanied minors. In a large number of cases, claims by asylum seekers of being below 18 years were not trusted by Swedish authorities. To handle the situation, the Swedish national board of forensic medicine (Rättsmedicinalverket, RMV) was assigned by the government to create a centralized system for medical age assessments. RMV introduced a procedure including two biological age indicators; x-ray of the third molars and magnetic resonance imaging of the distal femoral epiphysis. In 2017, a total of 9617 males and 337 females were subjected to this procedure. No validation study for the procedure was however published, and the observed number of cases with different maturity combinations in teeth and femur were unexpected given the claims originally made by RMV. We present a general stochastic model enabling us to study which combinations of age indicator model parameters and age population profiles are consistent with the observed 2017 data for males. We find that, contrary to some RMV claims, maturity of the femur, as observed by RMV, appears on average well before maturity of teeth. According to our estimates, approximately 15% of the tested males were children. These children had an approximate 33% risk of being classified as adults. The corresponding risk for an adult to be misclassified as a child was approximately 7%. We determine uncertainties and ranges of estimates under reasonable perturbations of the prior.

A 2-year follow-up MRI study for the evaluation of an age estimation method based on knee bone development.

Age estimation is an actual topic in the area of forensic medicine with a special focus on the age limits of 16 and 18 years. Current research on this topic relies on retrospective data of inhomogeneous populations relating to sex, age range, and socioeconomic status. In this work, we present a 2-year follow-up study for the evaluation of an age estimation method on a prospective magnetic resonance imaging (MRI) knee data collective of a homogeneous population. The study includes 40 male subjects from northern Germany aged 14 to 21 years. Three MRI examinations were evenly acquired within 2 years for each subject. As a first evaluation, a three-stage system was used to assess the ossification status of the knee (I:"open", II:"partially ossified", III:"fully ossified"). Three raters assessed the growth plate of the distal femur, proximal tibia, and proximal fibula based on central 2D slices. A good inter-rater agreement was attained (κ = 0.84). All subjects younger than 18 years were rated as stage I and had a cumulative knee score (SKJ) ≤ 5. Based on the follow-up datasets, new parameters quantifying the intra-individual ossification process were calculated. The results of this follow-up analysis show a different start, end, and speed of each growth plate's maturation as well as an ossification peak for individuals at the age of 16. The generated MRI database provides new insights into the ossification process over time and serves as a basis for further evaluations of age estimation methods.

How the Ends of Bones Evolve and What They Do: The Anatomical and Biomechanical Perspective.

Skeletal ossification occurs either directly within mesenchymal tissues or indirectly through a template of hyaline cartilage. Between the epiphyses and diaphyses of long bones, hyaline cartilaginous growth plates remain and constitute the progenitor cell reservoir from which the tissue develops toward the diaphysis and determines longitudinal bone size. Growth plates exhibit a characteristic architecture with columnar cell organization and different zonal morphology. The cells increase their volume toward the diaphysis, and eventually the longitudinally arranged septa of extracellular matrix mineralize. Finally, the mineralized cartilage matrix is replaced by lamellar bone. The extracellular matrix is rich in glycosaminoglycans, proteoglycans, and collagen II; at the edges of the growth plates, collagen I, III, and collagen X, especially at the mineralization front, are also present.The geometry of the growth plates is regulated by the local mechanical environment. In general, all plates orient themselves perpendicular to the resulting compressive force vector; grooves, ridges, and lateral angulations are adaptations to withstand shear forces acting on the growth plates. The final shape of the fully grown bone is determined not only by the epiphyseal growth plates but also by their apophyseal counterpart. Both structures respond in a comparable fashion to the local mechanical environment.

Physiologic and Pathologic Development of the Infantile and Adolescent Hip Joint: Descriptive and Functional Aspects.

The basic law of mechanobiology states that the external form and internal architecture of the skeleton and joints follow the functional stimuli that act upon them. Radiographs and magnetic resonance imaging reflect the loading history of the growing child, enabling an experienced radiologist to analyze the clinical functioning of patients by interpreting imaging studies. Concerning the hip joint, the physes of the coxal femoral end, the coxal femoral epiphysis with its epiphyseal growth plate, as well as the apophysis of the greater trochanter with its trochanteric growth plate, are the essential organ structures subject to internal forces. They determine the definitive geometric shape of the proximal femur. Indirectly they influence the appearance of the acetabulum and the centration of the hip joint.

Management of Juvenile Hallux Valgus Deformity: the role of combined Hemiepiphysiodesis.

BACKGROUND: This study aimed to investigate the efficacy of percutaneous hemiepiphysiodesis for gradual correction of symptomatic juvenile hallux valgus (HV) deformity. METHODS: Between 2012 to 2014, 24 patients with symptomatic juvenile HV were treated by combined percutaneous medial drilling hemiepiphysiodesis of the first proximal phalanx and lateral transphyseal screw hemiepiphysiodesis of the first metatarsal at our institution. Twenty-one of 24 patients fulfilled inclusion criteria had a complete radiological and clinical follow-up of at least 2 years. Preoperative and postoperative radiographs of the feet were reviewed for measurements of hallux valgus angle (HVA), intermetatarsal angle (IMA), proximal metatarsal articular angle (PMAA), proximal phalangeal articular angle (PPAA), and metatarsal length ratio (MTLR). Clinical outcomes were assessed using the AOFAS hallux metatarsophalangeal-interphalangeal score. RESULTS: The study included 21 consecutive patients (37 ft) for analysis. The mean age at surgery was 12.0 years (SD = 1.3) and mean follow-up after surgery was 35.1 months (SD = 6.0). With the data available, the HV deformity improved in terms of the reduction of HVA by a mean of 4.7 degrees (P < .001) and the reduction of IMA by 2.2 degrees (P < .001). The PMAA and PPAA also improved significantly in the anteroposterior plane; however, the PMAA difference was insignificant in lateral plane as expected. The mean difference in the MTLR was 0.00 (P = .216) which was indicative of no length discrepancy between first and second metatarsals. The AOFAS score increased from 68.7 to 85.2 (P < .001). In correlation analysis, time to physeal closure was significantly correlated with the final HVA change (r = -.611, P = .003). CONCLUSION: Although combined hemiepiphysiodesis does not create a large degree of correction as osteotomy, yet it did improve HV deformity with adequate growth remaining in our series. It is a procedure that can be of benefit to patients with symptomatic juvenile HV from this minimal operative approach before skeletal maturity. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Effect of Long-Term Diving on the Morphology and Growth of the Distal Radial Epiphyseal Plate of Young Divers: A Magnetic Resonance Imaging Study.

OBJECTIVE: To investigate the effects of long-term diving on the morphology and growth of the distal radial epiphyseal plate in young divers. STUDY DESIGN: Cohort study. SETTING: Guangzhou Sport University. PARTICIPANTS: Thirty-eight professional divers, aged 10 to 17 years, and 25 age-matched volunteers. INTERVENTIONS: Each subject received a physical examination at the beginning of the study and underwent bilateral magnetic resonance imaging of the wrist. The divers were divided into 2 groups depending on the status of the epiphyseal plate: group A (positive distal radial epiphyseal plate injury) and group B (no positive distal radial epiphyseal plate injury). A third group, group C, consisted of the 25 volunteers. MAIN OUTCOME MEASURES: The frequency of distal radial epiphyseal plate injury and the thickness of the distal radial epiphyseal plate were analyzed across the 3 groups. RESULTS: Twenty-nine cases (29/76, 38.15%) of distal radial epiphyseal plate injury were observed in 20 divers (20/38, 52.63%). The incidence of injury to the right hand was higher than that for the left (P = 0.009). There were statistically significant differences (P = 0.000) among the 3 groups in terms of epiphyseal plate thickness; group A > group B > group C. CONCLUSIONS: Distal radial epiphyseal plate injury is common in divers, and more injuries are seen in the right hand. Moreover, growth of the radius was impaired in divers relative to controls. We consider that loading during diving may influence growth of the epiphyseal plate in either a transient or permanent manner.