Yonsei Med J.  2022 Jul;63(7):683-691. 10.3349/ymj.2022.63.7.683.

Re-Assessment of Applicability of Greulich and Pyle-Based Bone Age to Korean Children Using Manual and Deep Learning-Based Automated Method

  • 1Department of Radiology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
  • 2Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
  • 3Department of Radiology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, College of Medicine, Pusan National University, Yangsan, Korea
  • 4University of Ulsan Foundation for Industry Cooperation, Ulsan, Korea
  • 5VUNO, Inc., Seoul, Korea
  • 6Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea


To evaluate the applicability of Greulich-Pyle (GP) standards to bone age (BA) assessment in healthy Korean children using manual and deep learning-based methods.
Materials and Methods
We collected 485 hand radiographs of healthy children aged 2–17 years (262 boys) between 2008 and 2017. Based on GP method, BA was assessed manually by two radiologists and automatically by two deep learning-based BA assessment (DLBAA), which estimated GP-assigned (original model) and optimal (modified model) BAs. Estimated BA was compared to chronological age (CA) using intraclass correlation (ICC), Bland-Altman analysis, linear regression, mean absolute error, and root mean square error. The proportion of children showing a difference >12 months between the estimated BA and CA was calculated.
CA and all estimated BA showed excellent agreement (ICC ≥0.978, p<0.001) and significant positive linear correlations (R2 ≥0.935, p<0.001). The estimated BA of all methods showed systematic bias and tended to be lower than CA in younger patients, and higher than CA in older patients (regression slopes ≤-0.11, p<0.001). The mean absolute error of radiologist 1, radiologist 2, original, and modified DLBAA models were 13.09, 13.12, 11.52, and 11.31 months, respectively. The difference between estimated BA and CA was >12 months in 44.3%, 44.5%, 39.2%, and 36.1% for radiologist 1, radiologist 2, original, and modified DLBAA models, respectively.
Contemporary healthy Korean children showed different rates of skeletal development than GP standard-BA, and systemic bias should be considered when determining children’s skeletal maturation.


Age determination by skeleton; radiography; hand bones; child; deep learning
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