title: Skeletal assessment and secular changes in knee development: a radiographic approach.
abstract: OBJECTIVE
  The purpose of this study is to conduct an analysis of ossification patterns in the distal femoral, proximal tibial, and proximal fibular epiphyses, and the patella. The results generated from this analysis will be compared with previous standards published by Elgenmark () and Garn et al. () to determine if clinical and skeletal age assessment standards should be updated for contemporary Americans.
  
  
  METHODS
  Using the Pediatric Radiology Interactive Atlas (Patricia), a total of 1,317 epiphyses were scored for presence or absence from radiographs of 1,056 white individuals born in or after 1990. Statistical modeling of epiphyseal appearance was conducted for all major percentiles, including the 5th and 95th percentiles through logistic regression.
  
  
  RESULTS
  Compared with Elgenmark () and Garn et al. (), our data suggest that the distal femoral and proximal tibial epiphyses show overall earlier ossification, while the proximal fibular epiphysis shows later ossification. When examining the pooled sex 50th percentile for our data, we found that ossification timing differences are 1.2 weeks earlier in the distal femoral epiphysis, 2.1 weeks earlier in the proximal tibial epiphysis, and 1.4 years later in the proximal fibular epiphysis.
  
  
  CONCLUSIONS
  The epiphyses that appear early in life, for example the distal femoral epiphysis, require gestational age information to accurately estimate appearance times. There are considerable differences between the ossification timing patterns presented in this study and those of previous standards, which did not include gestational ages. Several factors may explain the observed differences in the epiphyses of the knee including: the availability of gestational age information, the analysis of longitudinal versus cross-sectional data, differences in socioeconomic status and prenatal care, and secular change. KEYWORDS age estimation, growth standards, ossification, skeletal maturation, subadult/juvenile growth.
authors.affiliation: Department of Pathology and Anatomical Sciences, University of Missouri, Columbia, MO, 65212.|Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1102 Virgina Ave, Columbia, MO 65212.
authors.forename: M E
authors.initials: ME
authors.lastname: Boeyer
authors.affiliation: Department of Anthropology/Archaeology, Mercyhurst University, Erie, PA, 16546.
authors.forename: S D
authors.initials: SD
authors.lastname: Ousley
mesh_terms: D000365:Age Determination by Skeleton; D000885:Anthropology, Physical; D002648:Child; D002675:Child, Preschool; D004838:Epiphyses / Q000033:anatomy & histology / Q000000981:diagnostic imaging / Q000254:growth & development*; D005260:Female; D006801:Humans; D007719:Knee Joint / Q000033:anatomy & histology / Q000000981:diagnostic imaging / Q000254:growth & development*; D007867:Leg Bones / Q000033:anatomy & histology / Q000000981:diagnostic imaging / Q000254:growth & development*; D008297:Male; D011859:Radiography