Journal of Pediatric Orthopaedics - 2026-06-16 - Journal Article
Discrepancy Rates Between Skeletal Maturity Assessment Systems in Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis.
Neo BXB, Choo JSH, Wong HK, Liu KPG, Jun-Hao T
Topics
Key Takeaway
Risser staging overestimates skeletal maturity in AIS at a clinically significant rate, with Risser-mature/SMS-immature discordance occurring in 12.5% and Risser-mature/CVM-immature discordance in 24.3% of patients.
Summary Depth
Choose how much analysis to show on this article page.
Summary
This systematic review and meta-analysis quantified discordance rates between Risser staging, Sanders Maturity Scale (SMS), and cervical vertebral maturation (CVM) in AIS patients. Pooled Risser-vs-SMS overall discrepancy was 16.1% (95% CI: 11.6%–21.1%), with the clinically dangerous Risser-mature/SMS-immature pattern occurring in 12.5%. Risser-vs-CVM overall discrepancy reached 25.0% (95% CI: 20.4%–29.7%), driven almost entirely by Risser-mature/CVM-immature misclassification at 24.3%, suggesting Risser systematically declares maturity prematurely relative to both alternative systems.
Key Limitation
The underlying studies are heterogeneous in patient demographics, curve severity, and reference standard for true maturity, and the absence of pooled patient-level data prevents subgroup analysis by sex, curve type, or Risser grade transition point where discordance is most consequential.
Original Abstract
BACKGROUND
Accurate assessment of skeletal maturity is critical in the management of adolescent idiopathic scoliosis (AIS), as growth potential strongly predicts curve progression risk and guides intervention timing. However, discordance between commonly used skeletal maturity classification systems may lead to suboptimal decision-making.
METHODS
A systematic review and meta-analysis were performed in accordance with PRISMA guidelines. PubMed, Scopus, Embase, Cochrane Library, and Web of Science were searched from inception to August 31, 2025. Studies comparing 2 or more skeletal maturity classification systems in AIS were included. Discrepancy was defined as a disagreement in maturity classification (mature vs. immature) at the same clinical time point. Random-effects meta-analyses of proportions were performed to estimate pooled discrepancy rates.
RESULTS
Thirteen studies met the inclusion criteria, with 9 included in meta-analyses. For the Risser versus Sanders maturity scale (SMS), discrepancies occurred in 2 patterns: Risser-immature/SMS-mature (4.0%, 95% CI: 2.0%-5.9%) and Risser-mature/SMS-immature (12.5%, 95% CI: 7.4%-17.6%), yielding an overall discrepancy rate of 16.1% (95% CI: 11.6%-21.1%). For Risser versus cervical vertebral maturation (CVM), overall discrepancy was 25.0% (95% CI: 20.4%-29.7%), predominantly driven by Risser-mature/CVM-immature classifications (24.3%, 95% CI: 19.7%-28.9%). Single-study comparisons involving alternative systems demonstrated substantial variability in discrepancy rates.
CONCLUSIONS
Substantial discordance exists among skeletal maturity assessment systems in AIS, with Risser staging frequently overestimating skeletal maturity. Limited evidence suggests that SMS and CVM show closer alignment with clinical growth parameters and may more closely approximate remaining growth potential. A multimodal approach incorporating more granular maturity indices may improve treatment timing and clinical outcomes.
LEVEL OF EVIDENCE
Level III.