Skeletal Age Assessment from the Olecranon for Idiopathic Scoliosis at Risser Grade 0

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1 This is an enhance PF from The Journal of Bone an Joint Surgery The PF of the article you requeste follows this cover page. Skeletal Age Assessment from the Olecranon for Iiopathic Scoliosis at Risser Grae 0 Yann Philippe Charles, Alain iméglio, Feerico Canavese an Jean-Pierre aures J Bone Joint Surg Am. 2007;89: oi: /jbjs.g This information is current as of January 17, 2008 Reprints an Permissions Publisher Information Click here to orer reprints or request permission to use material from this article, or locate the article citation on jbjs.org an click on the [Reprints an Permissions] link. The Journal of Bone an Joint Surgery 20 Pickering Street, Neeham, MA

2 2737 COPYRIGHT Ó 2007 BY THE JOURNAL OF BONE AN JOINT SURGERY, INCORPORATE Skeletal Age Assessment from the Olecranon for Iiopathic Scoliosis at Risser Grae 0 By Yann Philippe Charles, M, Alain iméglio, M, Feerico Canavese, M, an Jean-Pierre aures, Ph, M Investigation performe at the Service Orthopéie Péiatrique, Hôpital Lapeyronie an Institut Universitaire e Recherche Clinique, UFR Méecine, Université Montpellier, Montpellier, France Backgroun: The main progression of iiopathic scoliosis occurs uring peak height growth velocity, which is between the ages of eleven an thirteen years in girls an thirteen an fifteen years in boys an correspons to the accelerating phase of pubertal growth. The Risser sign remains at grae 0 uring this stage of growth. Triraiate cartilage closure occurs at approximately twelve years of age in girls an fourteen years in boys, which is in the mile of this phase. In aition to regular height measurements, a more etaile evaluation of skeletal maturity woul be esirable prior to the ientification of Risser grae 1. From the metho of Sauvegrain et al., iméglio erive a simplifie metho base on the raiographic appearance of the olecranon, which allows skeletal age to be assesse in six-month intervals. The purpose of this stuy was to etermine the accuracy an the value of this simple metho for the follow-up of patients with scoliosis. Methos: Five raiographic images emonstrate the typical characteristics of the olecranon uring pubertal growth: two ossification nuclei, a half-moon image, a rectangular shape, the beginning of fusion, an complete fusion. This classification metho was evaluate by three experience an inepenent observers from lateral raiographs of the elbow in 100 boys an 100 girls with iiopathic scoliosis uring the time of peak height velocity. Skeletal ages were correlate with the integral Sauvegrain metho. The egree of interobserver concorance was etermine, an skeletal age was compare with chronological age an the time of triraiate cartilage closure. Results: For the three observers, the average concorance between the Sauvegrain an olecranon methos was excellent (r = for boys an r = for girls). The interobserver agreement was also excellent (r = for the olecranon metho an r = for the Sauvegrain metho for boys, an r = an r = 0.985, respectively, for girls). Skeletal an chronological age were consiere to correspon to each other within a six-month range for 49% of the boys an 51% of the girls, while 25% of the boys an 26% of the girls ha an avance skeletal age an 26% of boys an 23% of girls ha a elaye skeletal age. Triraiate cartilage closure occurre at the same time as the appearance of the rectangular shape of the olecranon in 65% of the boys an 61% of the girls, corresponing to skeletal ages of fourteen an twelve years, respectively. In 91% of the boys an 88% of the girls, the triraiate cartilage fuse within six months before to six months after the appearance of the rectangular shape of the olecranon, which occurre between the half-moon image an the beginning of fusion of the olecranon. Conclusions: The metho of assessing skeletal age from the olecranon allows skeletal maturity to be evaluate in regular six-month intervals uring the phase of peak height velocity. This metho is simple, precise, an reliable. It complements the Risser grae-0 an the triraiate cartilage evaluation. Level of Evience: Prognostic Level II. See Instructions to Authors for a complete escription of levels of evience. Skeletal maturity an remaining growth represent essential parameters that must be consiere in the evaluation of the risk of curve progression in iiopathic scoliosis. uval-beaupère et al. 1 as well as Lonstein an Carlson 2 emonstrate that the main progression of iiopathic scoliosis occurs at the time of the most rapi aolescent skeletal growth, which occurs aroun eleven to thirteen years of skeletal age in girls an thirteen to fifteen years in boys. This growth phase isclosure: The authors i not receive any outsie funing or grants in support of their research for or preparation of this work. Neither they nor a member of their immeiate families receive payments or other benefits or a commitment or agreement to provie such benefits from a commercial entity. No commercial entity pai or irecte, or agree to pay or irect, any benefits to any research fun, founation, ivision, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immeiate families, are affiliate or associate. J Bone Joint Surg Am. 2007;89: oi: /jbjs.g.00124

3 2738 FOR I IOPATHIC S COLIOSIS AT R ISSER G RAE 0 correspons to the accelerating phase of the pubertal growth iagram 3,4 an is characterize by a graual increase in the spinal growth rate 5. Peak height velocity is a reliable clinical marker for the preiction of remaining growth an the risk of curve progression in iiopathic scoliosis 6,7. Yet, uring this growth phase, the Risser sign 8 remains at grae 0. The Risser grae-1 sign appears only aroun a skeletal age of 13.5 years in girls an 15.5 years in boys 3,4. Most current clinical an raiographic markers o not help peiatric orthopaeic surgeons to reaily istinguish maturity levels prior to Risser grae 1. Triraiate cartilage closure is closely relate to peak height velocity 7,9, with this perio of accelerate spinal growth split into approximately two halves by the closure of the triraiate cartilage, which occurs aroun a skeletal age of twelve years in girls an fourteen years in boys 3,10. Triraiate cartilage closure is mainly use in the preoperative evaluation of the risk for the evelopment of a crankshaft phenomenon after posterior spinal fusion in patients with an immature spine an an open triraiate cartilage A more etaile evaluation of skeletal maturity woul be suitable uring Risser grae 0, which correspons to the phase of highest spinal growth velocity, in aition to a height measurement every six months an an assessment of the status of the triraiate cartilage. Precise information about maturity levels an remaining growth coul help to better evaluate the efficacy of brace treatment, the curve progression risk, or the potential for the evelopment of a crankshaft phenomenon. The metho of Sauvegrain et al. 16 for the assessment of skeletal age with use of raiographs of the elbow has been use in France over the last forty years, an a etaile analysis of this metho has emonstrate its reliability uring the time of peak growth velocity 17. This metho is use uring the accelerating phase of the pubertal growth iagram 3,4, from a skeletal age of eleven to thirteen years in girls an thirteen to fifteen years in boys, at which time the evelopment of elbow ossification centers is clearly ientifie. Complete elbow ossification correlates with the en of accelerate growth velocity an marks the beginning of the ecelerating growth phase. erive from the Sauvegrain metho, a simplifie metho escribe by iméglio et al. 4,17 is characterize by clear an regular morphological evelopment of the olecranon uring the accelerating growth phase. Assessment of this apophysis allows skeletal age to be evaluate very easily an accurately at intervals of six months. The purpose of this stuy was to etermine the accuracy of this simplifie metho of olecranon staging, to compare it with the time of triraiate cartilage closure, an to investigate its capacity to increase information on skeletal maturation uring Risser grae 0 in patients with iiopathic scoliosis. Materials an Methos The meical recors an raiographs of patients with juvenile or aolescent iiopathic scoliosis who were followe at our peiatric orthopaeic epartment between 1988 an 2006 were reviewe. From 561 complete an analyzable recors, the charts of 100 boys an 100 girls were ranomly selecte for this retrospective stuy. The patients ha to have been followe regularly every six months for a minimum of two years uring the phase of peak height velocity with a Risser grae 0 (between eleven an thirteen years of skeletal age in girls an between thirteen an fifteen years in boys). The clinical an raiographic evolution of the scoliosis ha to be well ocumente. Anteroposterior an lateral raiographs of the left elbow mae to assess the skeletal age uring this growth perio ha to be available. When more than one skeletal age assessment ha been performe, only the first elbow raiograph was retaine for the review in this stuy. Clinical growth parameters, such as staning height, sitting height, weight, an menarche, were ocumente on the checklist an the growth curve that is regularly use in our clinic. Patients with congenital scoliosis as well as scoliosis with an unerlying neurological isorer, a synrome, or an enocrinopathy were exclue from the stuy protocol. In juvenile iiopathic scoliosis, magnetic resonance imaging was carrie out in aition to clinical an neurological examinations to etect any neural axis abnormality. In the group of 100 boys, fifty-eight patients ha juvenile scoliosis, with an onset of between four an ten years, an forty-two ha aolescent scoliosis, with an onset after ten years. In the group of 100 girls, forty-nine patients ha a juvenile scoliosis an fifty-one ha an aolescent scoliosis. Staning an sitting height were measure in centimeters every six months, incluing five consecutive measurements uring two years, which allowe the calculation of average annual growth velocity for staning an sitting height, respectively, as follows: (last height measurement 2 first height measurement) / 2 (years). Age at menarche was also ocumente. The Sauvegrain metho is use shortly before the onset of puberty an uring the first two years of the pubertal growth spurt, from a skeletal age of ten to thirteen years in girls an twelve to fifteen years in boys 17. This metho etermines skeletal age from anteroposterior an lateral raiographs of the left elbow an is base on a 27-point scoring system, which assesses four ossification centers. The lateral conyle (1 to 9 points), the trochlea (1 to 5 points), the olecranon apophysis (1 to 7 points), an the proximal raial epiphysis (1 to 6 points) are rate accoring to their evelopmental stage. The scores are ae together, an the total score allows skeletal age in years to be assesse on a graph for girls an a graph for boys. These graphs contain typical scores of skeletal ages at intervals of six months, which allow a clear an regular ifferentiation of skeletal age uring the phase of peak height velocity. erive from the Sauvegrain metho, the simplifie olecranon metho evelope by iméglio 4,17 allows skeletal age in intervals of six months to be assesse easily an quickly. Five images of the olecranon are ientifie, with two ossification nuclei inicating eleven years of age in girls an thirteen years in boys; a half-moon image, 11.5 years in girls an 13.5 years in boys; a rectangular aspect, twelve years in girls an fourteen years in boys; the beginning of fusion, 12.5 years in girls an 14.5 years in boys; an a complete fusion, thirteen years in girls an fifteen years in boys (Fig. 1).

4 2739 FOR I IOPATHIC S COLIOSIS AT R ISSER G RAE 0 Fig. 1 Simplifie skeletal age assessment with the olecranon metho uring the accelerating pubertal growth phase of peak height velocity an Risser grae 0 from the ages of eleven to thirteen years in girls an from thirteen to fifteen years in boys, with a ecelerating growth phase after elbow fusion. Y cartilage closure = triraiate cartilage closure. In orer to compare this simplifie metho of skeletal age assessment from the olecranon with the entire Sauvegrain metho, the elbow raiographs of the 100 girls an 100 boys with iiopathic scoliosis were reviewe once by three inepenent an experience peiatric orthopaeic surgeons who ha all routinely use both methos for a minimum of two years in their practice. No time limit was impose for skeletal age etermination with use of the Sauvegrain metho or the olecranon metho, which were use respectively in two separate review sessions. Prior to the review, the name an age of the patient were omitte from all raiographs, which were marke with consecutive numbers from one to 200 by an iniviual who i not participate in the stuy. Apart from gener, information about the patients was not accessible to any of the observers uring the analysis of the raiographs. The skeletal age as well as the respective chronological age of the patient were then store in a ata file. After the review of the elbow raiographs was complete, the three observers analyze a series of five consecutive pos- teroanterior raiographs of the spine mae when the patient was at Risser grae 0 uring the growing perio of peak height velocity. The time of triraiate cartilage closure was compare with the chronological age an the skeletal age from the olecranon. Triraiate cartilage closure was consiere to correspon to stage 2 of the Oxfor metho 18 for assessing skeletal age from the pelvis. The raiographic status of the triraiate cartilage was iscusse by the three observers in orer to minimize intraobserver an interobserver errors. Statistical Analysis The concorance correlation coefficient of Lin 19 was use to analyze the concorance between skeletal age ata assesse with the olecranon metho an skeletal age ata assesse with the Sauvegrain metho for each observer separately. Furthermore, the concorance between the three observers was analyze for each metho of skeletal age assessment. Accoring to the Lanis an Koch scale for intraclass correlation coefficients 20, the concorance was consiere to be excellent if

5 2740 FOR I IOPATHIC S COLIOSIS AT R ISSER G RAE 0 r > 0.80, goo if r = 0.61 to 0.80, fair if r = 0.41 to 0.60, an poor if r Results Staning Height Velocity, Sitting Height Velocity, an Menarche Growth velocities of staning an sitting height were analyze uring the first two years of the pubertal growth spurt. Clinically, the beginning of this phase was etecte by a sharp increase in growth velocity when the skeletal age was approximately eleven years in girls an thirteen years in boys. In the boys, the average annual staning height velocity (an stanar eviation) was 8.11 ± 0.88 cm per year (range, 6.0 to 10.0 cm per year). The annual average sitting height velocity was 4.18 ± 0.67 cm per year (range, 2.5 to 5.5 cm per year). In the girls, the average annual staning height velocity was 7.22 ± 0.75 cm per year (range, 6.0 to 8.5 cm per year). The annual average sitting height velocity was 3.22 ± 0.62 cm per year (range, 2.0 to 4.5 cm per year). Menarche occurre at an average chronological age of ± 1.03 years (range, 11.0 to 16.0 years). Concorance Between the Olecranon an Sauvegrain Methos An excellent concorance was note between skeletal ages assesse by means of the olecranon metho an skeletal ages assesse with use of the Sauvegrain metho (average concorance, r = for boys an r = for girls). Correlation coefficients an respective confience intervals in Table I emonstrate that this fining applies for each of the three observers equally. There was no ifference when boys were compare with girls. Interobserver Concorance of the Olecranon an Sauvegrain Methos The correlation coefficients in Table II show that the concorance among the three observers was equally excellent for skeletal ages assesse by means of the olecranon metho or by the Sauvegrain metho. A comparison of the geners emonstrate no iscrepancy between the skeletal ages of boys an girls. Comparison of Chronological an Skeletal Age ata In the boys, the average chronological age was ± 1.01 years (range, 12.2 to 15.5 years), while the average skeletal age TABLE I Concorance Between the Olecranon Metho an the Sauvegrain Metho Concorance Correlation Coefficients (95% Confience Intervals) Observer Boys Girls ( ) ( ) ( ) ( ) ( ) ( ) TABLE II Interobserver Concorance for Olecranon an Sauvegrain Methos Olecranon metho Sauvegrain metho Concorance Correlation Coefficients (95% Confience Intervals) Boys Girls ( ) ( ) ( ) ( ) etermine with the olecranon metho was ± 0.69 years (range, 13.0 to 15.0 years). In the girls, the average chronological age was ± 1.16 years (range, 10.0 to 14.3 years), while the average skeletal age was ± 0.68 years (range, 11.0 to 13.0 years). Chronological age an skeletal age assesse with the olecranon metho were consiere to be the same if the ifference was less than six months. Skeletal age was efine as avance if it exceee chronological age by more than six months an as elaye if it was less than the chronological age by at least six months. Table III shows that chronological age an skeletal age correspone to one another within a sixmonth range in 49% of the boys an 51% of the girls. Triraiate Cartilage Closure The time of triraiate cartilage closure was compare with the chronological age an with the skeletal age assesse with the olecranon metho. The etermination of triraiate cartilage closure an skeletal age was base on the consensus of the three observers who worke together in this part of the stuy. However, this review of the spine raiographs an all available elbow raiographs for each patient was complete only after the initial review of inepenent skeletal age-graing ha been complete. In the boys, the average chronological age at the time of triraiate cartilage closure was ± 1.01 years (range, 12.4 to 16.2 years), an the average skeletal age was ± 0.44 years (range, 13.5 to 15.0 years). In the girls, the average chronological age at the time of triraiate cartilage closure was ± 0.87 years (range, 10.3 to 13.8 years), while the average skeletal age was ± 0.40 years (range, 11.5 to 13.0 years). Triraiate cartilage closure occurre at the time of the appearance of the rectangular shape of the olecranon apophysis in 65% of the boys an 61% of the girls an correspone to a skeletal age of fourteen years in the boys an twelve years in the girls (Fig. 1). In 91% of the boys an in 88% of the girls, triraiate cartilage closure occurre within six months before to six months after the appearance of the rectangular shape of the olecranon. iscussion The progression of scoliosis is closely relate to the beginning of the pubertal growth spurt 1,2,21, which is character-

6 2741 FOR I IOPATHIC S COLIOSIS AT R ISSER G RAE 0 TABLE III Skeletal Age Assesse from the Olecranon Compare with the Chronological Age in 100 Boys an 100 Girls Boys Girls Avance >6 months 25% 26% Corresponing 6 months 49% 51% elaye >6 months 26% 23% ize by a graual but major increase in spinal growth velocity with an increase in the risk of scoliosis progression 5,22,23. This phase of accelerating growth velocity lasts approximately two years, from eleven to thirteen years of skeletal age in girls an from thirteen to fifteen years in boys, with an average increase in sitting height of 7.5 cm in girls an 8.5 cm in boys 3,4. Little et al. 6 an Song an Little 7 emonstrate that peak height velocity, etermine with use of clinical staning height measurements, is a valuable marker to preict remaining growth. Growth curves in these stuies showe that a staning height velocity of >6 cm per year in girls an >8 cm per year in boys implies that the patient is within his or her greatest growth spurt. Analogue values reporte by iméglio 3,4 show that the average gain in sitting height uring the two years of peak height velocity is 14.5 cm in girls an 16.5 cm in boys. Retrospective height measurements in our stuy are comparable with those results an confirm that these patients were in the perio of their most rapi aolescent growth 3,4. Even if staning height velocity is use, it is important to consier sitting height velocity, which reflects trunk growth. These ual height measurements allow the etermination of the increase in the length of the lower limb segment an the increase in the spine length, events which occur nearly six months apart 5,10. Menarche is use for the follow-up an treatment of girls with iiopathic scoliosis. Menarche most often occurs when Fig. 2 Application of the olecranon metho in the evaluation of curve progression risk uring the accelerating pubertal growth phase of peak height velocityat Risser grae 0. Y cartilage closure = triraiate cartilage closure.

7 2742 FOR I IOPATHIC S COLIOSIS AT R ISSER G RAE 0 the rate of growth is slowing, at the beginning of the ecelerating growth phase, usually between the skeletal age of thirteen an 13.5 years, an it correspons to Risser grae 1 at the iliac apophysis 3,4. Little et al. 6 showe that menarche occurre at a meian of seven months after peak height velocity. For instance, at this stage of puberty, the average remaining growth approximates 4 cm on sitting height uring the phase of ecelerating growth velocity 5. Although chronological age was the only analyzable ata point to etermine menarchal age in the present stuy, our results confirm that menarche often occurs after peak height velocity. Furthermore, the large range of menarchal age from eleven to sixteen years in this stuy makes this inicator less precise when preicting remaining growth. However, menarche shoul be consiere as an approximate lanmark of the pubertal growth spurt, which inicates that spinal growth will probably cease two years after menarche if it occurs aroun Risser grae 1. The spinal growth velocity progressively ecreases from this point, which makes maximal curve progression unlikely following menarche 1,5. The Risser sign 8 is use wiely to assess spinal maturity, although the main risk for progression of iiopathic scoliosis occurs prior to the appearance of Risser grae 1 2,21. Risser grae 0 lasts for approximately two-thirs of the pubertal growth perio 5, an it nees to be segmente into clearer stages to allow for the evaluation of skeletal maturity in a more precise manner. Our stuy inicates that chronological age is an insufficient marker for the evaluation of skeletal maturity as chronological age correspone to skeletal age within a sixmonth range in only 49% of the boys an 51% of the girls. Skeletal age ata from the han an wrist accoring to the metho of the Greulich an Pyle atlas 24 are ifficult to assess precisely from the age of eleven to thirteen years in girls an from thirteen to fifteen years in boys because raiographic morphological changes are ifficult to interpret an because this atlas is not regularly ivie into six-month intervals uring this perio 17. Saners et al. 25,26 confirme that morphological changes in the wrist, raius, an ulna were not correlate to curve progression uring peak height velocity, but they presente a new metho of assessment of igital skeletal age erive from the Tanner-Whitehouse-3 metho, which is base on a raiographic analysis of the metacarpals an fingers 27. This metho provies several markers prior to Risser grae 1 an coul eventually a helpful information to Risser grae 0 in the future. The time of triraiate cartilage closure in the pelvis represents a valuable raiographic marker uring Risser grae 0. Song an Little 7 as well as Vital et al. 9 emonstrate that triraiate cartilage closure is closely relate to peak height velocity an precees the appearance of Risser grae 1. Triraiate cartilage closure occurs approximately halfway through the phase of accelerate growth velocity, between the ages of eleven an thirteen years in girls an between thirteen an fifteen years in boys 3,10. Our stuy confirms the fining that triraiate cartilage closure occurs aroun the age of twelve years in girls an aroun fourteen years in boys. When this raiographic marker in the pelvis was relate to skeletal age ata, the time frame when triraiate cartilage closure occurre became quite narrow, with full closure note between 11.5 an 12.5 years in 88% of the girls an between 13.5 an 14.5 years in 91% of the boys. This inicates that the triraiate cartilage status is a relatively precise marker for the evaluation of skeletal maturity uring Risser grae 0 even though it represents only one point uring a perio of peak height velocity of two years. The Sauvegrain metho uses the elbow to assess skeletal age uring this phase of the pubertal growth spurt 16. The introuction of aitional scores on the four ossification centers of the elbow an the evelopment of simplifie graphs for skeletal age assessment allowe improve reliability of this metho an simplifie its use 17. erive from this metho, the olecranon is characterize by a clear an regular morphological evelopment uring this perio. As escribe by iméglio et al. 4,17, graing of the olecranon apophysis allows one to evaluate skeletal age very easily in six-month intervals from the ages of eleven to thirteen years in girls an from thirteen to fifteen years in boys. The morphological sequence of five istinct images of the olecranon evelops over this relatively short perio of two years, making this metho simple to use every six months. Furthermore, the learning curve of this simplifie metho is short. In the present stuy, all three observers were familiar with this metho. Therefore, further stuies that inclue less experience observers woul be necessary to emonstrate that a novice to the metho is as accurate as one with experience. The results in the present stuy emonstrate that, although only one ossification center is consiere, the olecranon metho is as precise an reliable as the Sauvegrain metho for the evaluation of skeletal age from the age of eleven years in girls an thirteen years in boys, which is the stage of puberty when the growth velocity is increasing an is typically characterize by the occurrence of a secon ossification center on the olecranon apophysis. The skeletal age of twelve years in girls an fourteen years in boys correspons to the appearance of a typical rectangular shape of the olecranon ossification center. A concorance between this stage an the time of triraiate closure was note in 65% of the boys an in 61% of the girls. Complete fusion of the olecranon an all other elbow physes occurs at the skeletal age of thirteen years in girls an fifteen years in boys, which inicates that pubertal growth velocity ecreases rapily from this point of skeletal maturity. Complete olecranon physeal fusion ivies the two main phases of accelerating an ecelerating height velocity from each other 3,4. Accurate measures of maturity are require when evaluating the efficacy of brace treatment of scoliosis. uval- Beaupère et al. 1 emonstrate the importance of annual growth velocity an seconary sexual characteristics to ientify the beginning of the pubertal growth spurt, a ecisive perio for curve progression. Lonstein an Carlson 2 note that three strong fractures for the progression of iiopathic scoliosis were the curve magnitue along with the chronological age an the Risser sign 8. Nevertheless, patients with iiopathic juvenile scoliosis have a spinal eformity prior to the onset of the pubertal growth spurt an go through the entire perio of peak height velocity at Risser grae 0. The curve progression risk

8 2743 FOR I IOPATHIC S COLIOSIS AT R ISSER G RAE 0 with juvenile scoliosis is higher, with approximately half of these patients neeing surgical treatment Therefore, growth in these younger patients nees systematic follow-up. In aition to height measurements at six-month intervals, skeletal age assessment from the olecranon appears to be helpful in the evaluation of skeletal maturity. It complements the lack of information of Risser grae 0, which is the phase where 90% of surgically treate curves primarily increase 21, an it ais in the ientification of patients with juvenile scoliosis who are at higher risk of progression (Fig. 2). In Risser grae 0, the olecranon helps to ientify immature patients with scoliosis (i.e., patients with two ossification nuclei or a half-moon-shape nucleus of the olecranon) who are at risk of eveloping a crankshaft phenomenon at the posterior spinal fusion 11-15,31,32. The nee for an anterior anular release an iscectomy 33 to avoi remaining vertebral boy growth can be more accurately etermine an may be of use for patients treate with vertebral boy stapling 34,35. The morphological evelopment of the olecranon represents a simple but reliable metho of skeletal age assessment uring the phase of peak height velocity. It allows skeletal age to be etermine in regular six-month intervals from the ages of eleven to thirteen years in girls an from thirteen to fifteen years in boys. This information complements Risser grae 0, corresponing to the critical phase of accelerating growth velocity, an the triraiate cartilage closure, which occurs at aroun twelve years in girls an fourteen years in boys. Complete olecranon physeal fusion occurs between the two main phases of accelerating an ecelerating growth velocity uring puberty. This metho shoul be correlate with regular height measurements an Tanner stages. All of these parameters can help to better evaluate the efficacy of brace treatment, to ientify scoliosis that is at high risk of progressing uring pubertal growth, an to ientify patients who are at higher risk for eveloping the crankshaft phenomenon following posterior spinal fusion. n Yann Philippe Charles, M Alain iméglio, M Feerico Canavese, M Service Orthopéie Péiatrique, Hôpital Lapeyronie, 371, Av u oyen G. Girau, Montpellier Ceex 5, France. aress for Y.P. Charles: ypcharles@hotmail.com Jean-Pierre aures, Ph, M Institut Universitaire e Recherche Clinique, 641, Av u oyen G. Girau, Montpellier Ceex 5, France References 1. uval-beaupère G, ubousset J, Queneau P, Grossior A. [A unique theory on the course of scoliosis]. Presse Me. 1970;78: passim. French. 2. Lonstein JE, Carlson JM. The preiction of curve progression in untreate iiopathic scoliosis uring growth. J Bone Joint Surg Am. 1984; 66: iméglio A. Growth in peiatric orthopaeics. J Peiatr Orthop. 2001; 21: iméglio A. 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