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Evaluation of two methods of bone age assessment in peripubertal children in Zimbabwe

Evaluation of two methods of bone age assessment in peripubertal children in Zimbabwe
Evaluation of two methods of bone age assessment in peripubertal children in Zimbabwe

Objectives: 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.

Methods: 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.

Results: 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).

Conclusion: 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.

8756-3282
Kowo-Nyakoko, Farirayi
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Gregson, Celia L.
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Madanhire, Tafadzwa
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Stranix-Chibanda, Lynda
21d7417d-3fff-45b0-9558-62d445aef3b8
Rukuni, Ruramayi
c2632960-bd81-4238-b214-a6ec3121f899
Offiah, Amaka C.
ef1703e9-d951-4499-adb7-292bbd031bbd
Micklesfield, Lisa K.
e73dd95b-ce79-4dc4-b0be-a8935eb069c8
Cooper, Cyrus
e05f5612-b493-4273-9b71-9e0ce32bdad6
Ferrand, Rashida A.
9441b7cd-4eb5-4665-aa69-357911fd2c87
Rehman, Andrea M.
70df2a8e-aa95-4942-ad10-4644280f13bf
Ward, Kate A.
39bd4db1-c948-4e32-930e-7bec8deb54c7
Kowo-Nyakoko, Farirayi
51536d0c-2313-404d-bd3b-881b741d540f
Gregson, Celia L.
ebd937a1-1e99-42f8-b278-95fce091d8f0
Madanhire, Tafadzwa
24f2c09f-1ee3-4674-9bf6-e201e1d17f6d
Stranix-Chibanda, Lynda
21d7417d-3fff-45b0-9558-62d445aef3b8
Rukuni, Ruramayi
c2632960-bd81-4238-b214-a6ec3121f899
Offiah, Amaka C.
ef1703e9-d951-4499-adb7-292bbd031bbd
Micklesfield, Lisa K.
e73dd95b-ce79-4dc4-b0be-a8935eb069c8
Cooper, Cyrus
e05f5612-b493-4273-9b71-9e0ce32bdad6
Ferrand, Rashida A.
9441b7cd-4eb5-4665-aa69-357911fd2c87
Rehman, Andrea M.
70df2a8e-aa95-4942-ad10-4644280f13bf
Ward, Kate A.
39bd4db1-c948-4e32-930e-7bec8deb54c7

Kowo-Nyakoko, Farirayi, Gregson, Celia L., Madanhire, Tafadzwa, Stranix-Chibanda, Lynda, Rukuni, Ruramayi, Offiah, Amaka C., Micklesfield, Lisa K., Cooper, Cyrus, Ferrand, Rashida A., Rehman, Andrea M. and Ward, Kate A. (2023) Evaluation of two methods of bone age assessment in peripubertal children in Zimbabwe. Bone, 170, [116725]. (doi:10.1016/j.bone.2023.116725).

Record type: Article

Abstract

Objectives: 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.

Methods: 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.

Results: 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).

Conclusion: 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.

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Accepted/In Press date: 28 February 2023
e-pub ahead of print date: 3 March 2023
Published date: 1 May 2023
Additional Information: PhD funding support from the University of Southampton Global Challenges Research Fund and Faculty of Medicine, and part-funding from UK Medical Research Council Program U105960371. RAF is funded by the Wellcome Trust (206316_Z_17_Z). The IMVASK study was funded by the Wellcome Trust through a fellowship to RR (206764/Z/17/Z). For the purpose of open access, the author has applied a CC BY public copyright licence.

Identifiers

Local EPrints ID: 475194
URI: http://eprints.soton.ac.uk/id/eprint/475194
ISSN: 8756-3282
PURE UUID: 7e9f7942-b7fc-4937-bd54-84a41bd0688d
ORCID for Cyrus Cooper: ORCID iD orcid.org/0000-0003-3510-0709
ORCID for Kate A. Ward: ORCID iD orcid.org/0000-0001-7034-6750

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Date deposited: 13 Mar 2023 17:53
Last modified: 03 May 2023 01:46

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Contributors

Author: Farirayi Kowo-Nyakoko
Author: Celia L. Gregson
Author: Tafadzwa Madanhire
Author: Lynda Stranix-Chibanda
Author: Ruramayi Rukuni
Author: Amaka C. Offiah
Author: Lisa K. Micklesfield
Author: Cyrus Cooper ORCID iD
Author: Rashida A. Ferrand
Author: Andrea M. Rehman
Author: Kate A. Ward ORCID iD

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