Background: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on a patient’s skeletal maturity. To be clinically useful, radiologic assessments of skeletal maturity must demonstrate acceptable interrater reliability and accuracy. Purpose: The purpose of this study was to examine the interrater reliability among surgeons of varying experience levels and specialty training backgrounds when evaluating the skeletal maturity of the distal femur and proximal tibia of children and adolescents with patellofemoral instability. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Six fellowship-trained orthopaedic surgeons (3 pediatric orthopaedic, 2 sports medicine, and 1 with both) who perform a high volume of patellofemoral instability surgery examined 20 blinded knee radiographs and magnetic resonance images in random order. They assessed these images for clinically relevant growth (open physis) or clinically insignificant growth (closing/closed physis) remaining in the distal femoral and proximal tibial physes. Fleiss' kappa was calculated for each measurement. After initial ratings, raters discussed consensus methods to improve reliability and assessed the images again to determine if training and new criteria improved interrater reliability. Results: Reliability for initial assessments of distal femoral and proximal tibial physeal patency was poor (kappa range, 0.01-0.58). After consensus building, all assessments demonstrated almost-perfect interrater reliability (kappa, 0.99 for all measurements). Conclusion: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on radiologic assessment of skeletal maturity. This study found that initial interrater reliability of physeal patency and clinical decision making was unacceptably low. However, with the addition of new criteria, a consensus-building process, and training, these variables became highly reliable.
Bibliographical noteFunding Information:
One or more of the authors has declared the following potential conflict of interest or source of funding: P.D.F. has received education payments from Smith & Nephew and hospitality payments from Medical Device Business Services. D.W.G. has received consulting fees from Arthrex; speaking fees from AO Trauma and Arthrex; faculty/speaker fees from Synthes; and royalties from Arthrex, Current Opinion in Pediatrics, Pega Medical, and Wolters Kluwer Health. S.M.S. has received research support from JRF and Vericel; consulting fees from DePuy/Medical Device Business Services, Moximed, Pfizer, and Smith & Nephew; speaking fees from Organogenesis and Vericel; royalties from Organogenesis; and hospitality payments from Fidia Pharma and Stryker. E.J.W. has received consulting fees from OrthoPediatrics. D.N.M. has received royalties from Springer. J.M.B. has received education payments and speaking fees from Steelhead Surgical and consulting fees from Smith & Nephew. H.B.E. has received education payments from Pylant Medical; faculty/speaker fees from Smith & Nephew, Pylant Medical, and Synthes; and hospitality payments from Arthrex. J.F. has received research support from Active Implants, Arthrex, Episurf, Fidia, JRF Ortho, Moximed, Novartis, Organogenesis, Samumed, Vericel, and Zimmer Biomet; education payments from Crossroads Orthopedics; consulting fees from Aesculap/B. Braun, Cartiheal, Cook Biotech, DePuy, Exactech, Moximed, Organogenesis, Regentis, RTI Surgical, Samumed, and ZKR Orthopedics; speaking fees from Aastrom Biosciences, Arthrex, Moximed, Organogenesis, and Vericel; royalties from Arthrex, Biopoly, DePuy, Organogenesis, Springer, and Thieme; and hospitality payments from Skeletal Kinetics. J.F. also has stock/stock options in MedShape and Ortho Regenerative Tech. B.E.H. has received education payments from Arthrex and Kairos Surgical, other financial or material support from Allosource and Vericel, and royalties from Springer and has stock/stock options in Imagen Technologies. J.L.K. has received education payments from Medwest and consulting fees from Flexion Therapeutics, has stock/stock options in Acuitive and Marrow Access Technologies, and is an employee of Marrow Access Technologies. D.K. has received education payments from Kairos Surgical and other financial or material support from Arthrex. R.A.M. has received research support from Zimmer, education payments from CDC Medical, and other financial or material support from Arthrex. L.H.R. has received education payments from Arthrex and consulting fees from GLG Consulting and Relief Health and has stock/stock options in Relief Health. S.L.S. has received research support from Arthrex; grant funding from DJO; education payments from Elite Orthopedics; and consulting fees from Arthrex, Ceterix, ConMed Linvatec, Flexion Therapeutics, GLG Consulting, JFR Ortho, Moximed, Olympus, and Vericel. M.T. has received grant support from DJO. P.W. has received research support from AlloSource and Ossur, education payments from Pylant Medical, and royalties from Elsevier. B.E.S.S. has received consulting fees, speaking fees, and royalties from Arthrex. S.N.P. has received education payments from CDC Medical, speaking fees from Synthes, and royalties from Wolters Kluwer Health. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
© The Author(s) 2021.
- physis; physes
- skeletal immaturity