MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton General Hospital, Tremona Road, SO16 6YD Southampton, UK; Biomedical Research and Training Institute, 10 Seagrave Road, Avondale Harare, Zimbabwe; Department of Medical Physics and Imaging Sciences, University of Zimbabwe- Faculty of Medicine and Health Sciences, Parirenyatwa Group of Hospitals, Mazowe Street, Harare, Zimbabwe.
Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol BS10 5NB, UK; SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.
Bone. 2023 May;170:116725. doi: 10.1016/j.bone.2023.116725. Epub 2023 Mar 3.
Bone age (BA) measurement in children is used to evaluate skeletal maturity and helps in the diagnosis of growth disorders in children. The two most used methods are Greulich and Pyle (GP), and Tanner and Whitehouse 3 (TW3), both based upon assessment of a hand-wrist radiograph. To our knowledge no study has compared and validated the two methods in sub-Saharan Africa (SSA), and only a few have determined BA despite it being a region where skeletal maturity is often impaired for example by HIV and malnutrition. This study aimed to compare BA as measured by two methods (GP and TW3) against chronological age (CA) and determine which method is most applicable in peripubertal children in Zimbabwe.
We conducted a cross-sectional study of boys and girls who tested negative for HIV. Children and adolescents were recruited by stratified random sampling from six schools in Harare, Zimbabwe. Non-dominant hand-wrist radiographs were taken, and BA assessed manually using both GP and TW3. Paired sample Student t-tests were used to calculate the mean differences between BA and chronological age (CA) in boys and girls. Bland-Altman plots compared CA to BA as determined by both methods, and agreement between GP and TW3 BA. All radiographs were graded by a second radiographer and 20 % of participants of each sex were randomly selected and re-graded by the first observer. Intraclass correlation coefficient assessed intra- and inter-rater reliability and coefficient of variation assessed precision.
We recruited 252 children (111 [44 %] girls) aged 8.0-16.5 years. The boys and girls were of similar mean ± SD CA (12.2 ± 2.4 and 11.7 ± 1.9 years) and BA whether assessed by GP (11.5 ± 2.8 and 11.5 ± 2.1 years) or TW3 (11.8 ± 2.5 and 11.8 ± 2.1 years). In boys BA was lower than CA by 0.76 years (95 % CI: -0.95, -0.57) when using GP, and by 0.43 years (95 % CI: -0.61, -0.24) when using TW3. Among the girls there was no difference between BA and CA by either GP [-0.19 years (95 % CI: -0.40, 0.03)] or TW3 [0.07 years (95 % CI: -0.16, 0.29)]. In both boys and girls, there were no systematic differences between CA and TW3 BA across age groups whereas agreement improved between CA and GP BA as children got older. Inter-operator precision was 1.5 % for TW3 and 3.7 % for GP (n = 252) and intra-operator precision was 1.5 % for TW3 and 2.4 % for GP (n = 52).
The TW3 BA method had better precision than GP and did not systematically differ from CA, meaning that TW3 is the preferred method of assessment of skeletal maturity in Zimbabwean children and adolescents. TW3 and GP methods do not agree for estimates of BA and therefore cannot be used interchangeably. The systematic differences in GP BA assessments over age means it is not appropriate for use in all age groups or stages of maturity in this population.
骨龄（BA）测量用于评估骨骼成熟度，并有助于儿童生长障碍的诊断。最常用的两种方法是 Greulich 和 Pyle（GP）和 Tanner 和 Whitehouse 3（TW3），两者均基于对手腕 X 光片的评估。据我们所知，在撒哈拉以南非洲（SSA）地区，还没有研究比较和验证这两种方法，尽管该地区骨骼成熟度经常受到影响，例如 HIV 和营养不良。本研究旨在比较两种方法（GP 和 TW3）测量的 BA 与实际年龄（CA），并确定哪种方法最适用于津巴布韦的青春期前儿童。
我们对 HIV 检测呈阴性的男孩和女孩进行了一项横断面研究。从津巴布韦哈拉雷的六所学校通过分层随机抽样招募儿童和青少年。拍摄非优势手的腕关节 X 光片，并使用 GP 和 TW3 手动评估 BA。使用配对样本学生 t 检验计算男孩和女孩中 BA 与 CA 之间的平均差异。Bland-Altman 图比较了两种方法确定的 CA 与 BA，并比较了 GP 和 TW3 BA 之间的一致性。所有 X 光片均由第二位放射科医生进行分级，并且随机选择每个性别组的 20%的参与者，并由第一位观察者重新分级。组内相关系数评估内部和组间可靠性，变异系数评估精密度。
我们招募了 252 名儿童（111 名[44%]女孩），年龄 8.0-16.5 岁。男孩和女孩的平均 CA（12.2 ± 2.4 和 11.7 ± 1.9 岁）和 BA 相似，无论是使用 GP（11.5 ± 2.8 和 11.5 ± 2.1 岁）还是 TW3（11.8 ± 2.5 和 11.8 ± 2.1 岁）评估。在男孩中，使用 GP 时 BA 比 CA 低 0.76 岁（95%CI：-0.95，-0.57），使用 TW3 时 BA 比 CA 低 0.43 岁（95%CI：-0.61，-0.24）。在女孩中，GP [-0.19 岁（95%CI：-0.40，0.03）]或 TW3 [0.07 岁（95%CI：-0.16，0.29）]之间 BA 与 CA 之间没有差异。在男孩和女孩中，CA 和 TW3 BA 之间没有年龄组之间的系统差异，而随着儿童年龄的增长，CA 和 GP BA 之间的一致性有所提高。TW3 的操作员间精密度为 1.5%，GP 为 3.7%（n=252），TW3 的操作员内精密度为 1.5%，GP 为 2.4%（n=52）。
TW3 BA 方法的精密度优于 GP，并且与 CA 没有系统差异，这意味着 TW3 是评估津巴布韦儿童和青少年骨骼成熟度的首选方法。TW3 和 GP 方法对 BA 的估计值不一致，因此不能互换使用。GP BA 评估在年龄上的系统差异意味着它不适用于该人群所有年龄组或成熟阶段。
