title: Simplified skeletal maturity scoring system: learning curve and methods to improve reliability.
abstract: METHODS
  Retrospective radiographical review by 5 independent observers.
  
  
  OBJECTIVE
  To validate the intra- and interobserver reliability of the simplified skeletal maturity scoring (SSMS) system in a large cohort for each stage and for the overall cohort.
  
  
  BACKGROUND
  The SSMS has been used to successfully predict curve progression in idiopathic scoliosis.
  
  
  METHODS
  A total of 275 patients with scoliosis (8-16 yr) with 1 hand radiograph were included from 2005 to 2011. Five participants independently scored images on 2 separate occasions using the SSMS (stage, 1-8). Observers (listed in order of increasing SSMS experience) included orthopedic surgery resident, clinical fellow (CF), research fellow, and senior faculty. Intraobserver agreement between the 2 sets of scores was estimated using the Pearson and Spearman rank correlation coefficients. Interobserver agreement was estimated with the unweighted Fleiss κ coefficient for the overall cohort and for junior (orthopedic surgery resident, CF, research fellow) versus senior faculty.
  
  
  RESULTS
  Intrarater reliability for orthopedic surgery resident, CF, research fellow, senior faculty was 0.956, 0.967, 0.986, 0.991, and 0.998, respectively (Spearman). Intrarater agreement improved with greater familiarity using the SSMS. The inter-rater reliability for junior faculty (κ = 0.65), senior faculty (κ = 0.652), and the overall group (κ = 0.66) indicated agreement between all observers but no improved inter-rater agreement with experience. However, 98% of disagreements occurred only within 1 stage. Stages 2, 3, and 4 accounted for most of the variability; stage 3 was the most commonly scored stage, corresponding to peak growth velocity.
  
  
  CONCLUSIONS
  The SSMS has excellent intraobserver agreement with substantial interobserver agreement. Intraobserver--but not interobserver agreement--improves with familiarity using the SSMS. Expectancy bias may contribute to a higher likelihood of assigning an SSMS 3. Discrepancies when classifying stages 2 to 4 may be resolved by improved descriptions of epiphyseal capping in stages 2 and 3.
  
  
  METHODS
  2.
authors.affiliation: *Department of Orthopaedic Surgery, Nemours/A.I. duPont Hospital for Children, Wilmington, DE †Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA ‡Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY; and §Project Research Consulting.
authors.forename: Kushagra
authors.initials: K
authors.lastname: Verma
authors.forename: Prakash
authors.initials: P
authors.lastname: Sitoula
authors.forename: Peter
authors.initials: P
authors.lastname: Gabos
authors.forename: Kerry
authors.initials: K
authors.lastname: Loveland
authors.forename: James
authors.initials: J
authors.lastname: Sanders
authors.forename: Satyendra
authors.initials: S
authors.lastname: Verma
authors.forename: Suken A
authors.initials: SA
authors.lastname: Shah
mesh_terms: D000293:Adolescent; D001846:Bone Development; D001842:Bone and Bones / Q000000981:diagnostic imaging*; D002648:Child; D018450:Disease Progression; D005260:Female; D006225:Hand / Q000000981:diagnostic imaging*; D006801:Humans; D008297:Male; D015588:Observer Variation; D011859:Radiography; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012600:Scoliosis / Q000000981:diagnostic imaging*