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Accuracy of the Sauvegrain Method in Determining Skeletal Age During Puberty
Alain Diméglio, MD1; Yann Philippe Charles, MD1; Jean-Pierre Daures, PhD, MD2; Vincenzo de Rosa, MD1; Boniface Kaboré, MD1
1 Service d'Orthopédie Pédiatrique, Hôpital Lapeyronie, 371 Avenue du Doyen G. Giraud, F-34295 Montpellier Cedex 5, France. E-mail address for A. Diméglio: a-dimeglio@chu-montpellier.fr
2 Institut Universitaire de Recherche Clinique, 641 Avenue du Doyen G. Giraud, F-34093 Montpellier Cedex 5, France
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Service d'Orthopédie Pédiatrique, Hôpital Lapeyronie, Montpellier, and the Institut Universitaire de Recherche Clinique, Montpellier, France

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Aug 01;87(8):1689-1696. doi: 10.2106/JBJS.D.02418
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: The method of Sauvegrain et al. for the assessment of skeletal age from radiographs of the elbow is useful during the two years of the pubertal growth spurt. The purpose of this study was to determine the accuracy of the method and its value in pediatric orthopaedics.

Methods: The Sauvegrain method uses four anatomical landmarks of the elbow: the lateral condyle, trochlea, olecranon apophysis, and proximal radial epiphysis. It is based on a 27-point scoring system. The scores for these structures are summed, and a total score is determined. A graph is then used to determine the skeletal age. The method was evaluated by three independent observers who used it to assess skeletal age on anteroposterior and lateral radiographs of the left elbow of sixty boys and sixty girls and compared the results with assessments made with use of the Greulich and Pyle atlas on posteroanterior radiographs of the left hand and wrist. Skeletal age determinations were performed twice by each observer at a four-week interval.

Results: The skeletal age determination from radiographs of the elbow was more precise because a clear semiannual age determination was possible. On the basis of the rating by the observers, the Sauvegrain method presented excellent interobserver correlation (r = 0.93) and excellent reproducibility (r = 0.96). The correlation between the methods of Sauvegrain et al. and Greulich and Pyle was good (r = 0.85). Nevertheless, certain elbow growth centers showed an intermediate developmental morphology, which failed to correspond to the score described by Sauvegrain et al. This led to errors in the interpretation of data. We suggest an intermediate score for these cases, and we modified the original graph to make it more accurate.

Conclusions: The modified method of Sauvegrain et al. is simple, reliable, and reproducible, and it complements the Greulich and Pyle atlas. In clinical practice, maturity can best be evaluated by associating skeletal age, annual growth rate, and secondary sexual characteristics. Therefore, this method is useful when major decisions such as the timing of epiphysiodesis or spinal arthrodesis are necessary during puberty.

Level of Evidence: Diagnostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Alain Dimeglio, M.D.
    Posted on October 03, 2005
    Dr. Dimeglio and colleagues respond to Dr. Kosuwon
    Dept. of Pediatric Orthopaedics, University of Montpellier, FRANCE

    We thank Dr. Kosowon for his letter.

    Average values and standard deviations of scores as well as skeletal ages determined by the method of Sauvegrain, et al, and by the Greulich and Pyle atlas are summarized in tables below for each evaluator, girls and boys, first and second review:

    Girls
    Review 1

    Score Sauvegrain

    Age Sauvegrain

    Age Greulich and Pyle

    Mean

    Std. dev.

    Mean

    Std. dev.

    Mean

    Std. dev.

    Observer 1

    21.90

    4.08

    11.47

    0.79

    11.53

    1.28

    Observer 2

    22.17

    4.12

    11.51

    0.79

    11.83

    0.87

    Observer 3

    22.49

    3.38

    11.44

    0.65

    11.91

    0.89

    Girls
    Review 2

    Score Sauvegrain

    Age Sauvegrain

    Age Greulich and Pyle

    Mean

    Std. dev.

    Mean

    Std. dev.

    Mean

    Std. dev.

    Observer 1

    21.79

    4.10

    11.44

    0.83

    11.73

    1.15

    Observer 2

    21.99

    4.22

    11.51

    0.83

    11.82

    0.91

    Observer 3

    22.28

    3.39

    11.43

    0.66

    11.77

    1.01

    Boys
    Review 1

    Score Sauvegrain

    Age Sauvegrain

    Age Greulich and Pyle

    Mean

    Std. dev.

    Mean

    Std. dev.

    Mean

    Std. dev.

    Observer 1

    20.69

    3.58

    13.68

    0.73

    13.53

    0.80

    Observer 2

    20.92

    3.42

    13.77

    0.74

    13.61

    0.71

    Observer 3

    21.40

    3.46

    13.90

    0.82

    13.69

    0.93

    Boys
    Review 2

    Score Sauvegrain

    Age Sauvegrain

    Age Greulich and Pyle

    Mean

    Std. dev.

    Mean

    Std. dev.

    Mean

    Std. dev.

    Observer 1

    20.50

    3.80

    13.64

    0.86

    13.47

    0.83

    Observer 2

    21.00

    3.56

    13.77

    0.79

    13.72

    0.77

    Observer 3

    21.12

    3.64

    13.81

    0.80

    13.49

    0.85

    The Bland and Altman method is a graphical method using means and standard deviations of two compared values. The data of our study has been reevaluated by Prof. J.-P. Daures at the Department of Clinical Research, University of Montpellier, France. Overall this data confirmed the results assessed by the use of intraclass correlation coefficients. Because of the huge amount of data, we would not recommend to publish all of it. Nevertheless, we can send you some of these results if you specify which part of the evaluation in our study represents a major interest for the use of the Bland and Altman method.

    Alain Diméglio, M.D.

    Yann Philippe Charles, M.D.

    Jean-Pierre Daures, M.D.

    Department of Pediatric Orthopaedics

    University of Montpellier, France

    Weerachai Kosuwon, M.D.
    Posted on August 24, 2005
    Determining Skeletal Age During Puberty
    Orthopedic Dept., Faculty of Medicine, Khon Kaen University, Khon Kaen, THAILAND

    To The Editor:

    I read with interest "Accuracy of The Sauvegrain Method in Determining Skeletal Age During Puberty" (87:1689-1692,2005),by Dimeglio, et al. This well conducted study aimed to evaluate the reliability of the scoring systems for assessment of skeletal age from radiographs of the elbow. The authors analyzed the data by using intraclass correlation coefficients. However, they did not provide the scores of each evaluator which are crucial for verification of the variability of the two methods of skeletal age assessment.

    Moreover, the intraclass correlation coefficient is often used to quantify the strength of relationship between two varibles. I think the Bland and Altman method(1) is more appropriate to assess the accuracy or repeatability of duplicate observations in this article. I would suggest that the authors recalculate the agreement of the three observers again by using the Bland and Altman method(2).

    Weerachai Kosuwon, M.D.

    MSc (Clinical Epidemiology)

    References:

    1. Stanton A. Glantz, Primer of Biostatistics 5th edition. Chicago: McGrawHill;2002, p230-283.

    2. Bland MJ, Altman DG, Statistical Methods for Assessing Agreement Between Two Measures of Clinical Measurement. Lancet1(8476):307-310,1986.

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