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Surprising Evidence of Pelvic Growth (Widening) after Skeletal Maturity

Surprising Evidence of Pelvic Growth (Widening) after Skeletal Maturity

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Surprising Evidence of Pelvic Growth (Widening) after SkeletalMaturity
Alexander A. Berger,
1
Ryan May,
2
Jordan B. Renner,
3
Neal Viradia,
1
Laurence E. Dahners
1
1
Department of Orthopaedics, University of North Carolina, CB #7055, Bioinformatics Building, Chapel Hill, North Carolina 27599-7055,
2
Department of Biostatistics, University of North Carolina, CB #7420, 3101 McGavran-Greenberg Hall, Chapel Hill, North Carolina 27599-7055,
3
Department of Radiology, University of North Carolina, CB #7510, 2006 Old Clinic Chapel Hill, North Carolina 27599-7055
 Received 22 December 2010; accepted 5 May 2011 Published online 23 May 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/jor.21469
ABSTRACT:
Following an increase in length and width during childhood and adolescence, skeletal growth is generally assumed tostop. This study investigates the influence of aging on the dimensions of the pelvis and the L4 lumbar vertebra during adulthood. Thedimensions of the pelvis, L4 vertebra, and femoral heads were calculated for 246 patients who had received pelvic and abdominalComputed Tomography scans from the UNC Health Care System. Linear regression analysis determined the significance of relation-ships between age and width of the pelvis. There was a strong correlation between increasing patient age and increasing width of thepelvis at the trochanters, (0.333 mm/year of age p
<
0.0001), at the iliac wings, (0.371 mm/year of age p
<
0.0002), and between thefemoral heads, indicating that the bony pelvis widens over 20 mm between the ages of 20 and 80. The pelvic inlet did not enlarge overtime while the distance between the hips and the femoral head diameter did significantly increase. The height of L4 did not increaseover time, but the L4 width did increase. These correlations were seen in both genders. Surprisingly, our results suggest that the pelvisand L4 vertebra increase in width after skeletal maturity and cessation of longitudinal growth.
ß
2011 Orthopaedic Research Society.Published by Wiley Periodicals, Inc. J Orthop Res 29:1719–1723, 2011.
Keywords:
bone growth; pelvic widening; bone maturation; longitudinal growth; computed tomography
During childhood and young adulthood our bones growin both length and width. Bone widens by periostealapposition, a process which slows during aging.
1
Bonewidening also occurs in later years and this is thoughtto be an adaptive response to compensate for the lossof strength produced by endocortical bone loss. In a 7- year prospective study of over 600 women, Szulc et al.
2
reported that rates of endocortical resorption increasedwith age, while the rate of periosteal apposition de-creased with age, resulting in a decrease in the massof the bone. Other research also supports an increasein skeletal bone width in postmenopausal women as aresult of periosteal apposition.
3,4
In a previous radiographic study of trochantericbursitis, we noted that the width of the entire pelvisincreased with age after skeletal maturity (unpub-lished data). We were surprised by this apparent indi-cation of growth in width of the skeleton postmaturity. We searched for previous studies indicating such pelvic enlargement and were unable to find infor-mation in the literature regarding post maturitychanges in the actual width of the skeleton (as opposedto simply the dimensions of the bones themselves). Incritical discussions of these findings, there were anumber of serious questions advanced. We developedseveral hypotheses that might explain this unexpectedfinding. The first was that, as patients became moreobese with age, the greater distance between the pelvisand plain radiographic plates would increase, inducing greater magnification on X-rays and apparentincreases in pelvic dimensions. Therefore, weembarked on this present study in which we usedcomputed tomography data (not subject to magnifica-tion) to more carefully investigate the dimensionalchanges in the pelvic bones. Another hypothesis wasforwarded that, because our data represented a crosssection of the population rather than a longitudinalfollow-up of individuals, we might have an inadvertentselection bias wherein somehow we had selected largerindividuals in our older age groups. Thus in this studywe elected to also measure the height of the L4 verte-bral body as some indication of whether our olderpatients were also taller (larger overall). The thirdhypothesis assumed that the pelvis was truly enlarg-ing and that any such widening of the pelvis would bedue to periosteal appositional bone formation ratherthan true enlargement or ‘‘growth.’’ Therefore, we alsomeasured the width of the pelvic inlet which weexpected would diminish or narrow from the additionof periosteal new bone. We also measured the distancebetween the femoral heads which we assumed wouldnot be changed by periosteal apposition. Finally wemeasured the diameters of the femoral heads as theydo not have a periosteum with which to produce appo-sitional growth.
METHODS
This study was approved by the ethics committee of the Uni-versity of North Carolina. We included patients age 20–79.Diagnostic exclusion criteria included the presence of eitherpelvic/vertebral column implants or noticeable abnormalitiesin the normal anatomy of the pelvis/vertebral column suchas scoliosis, osteophytosis, or leg length inequality.
Patients
The researchers used picture archiving and communicationSystem (PACS) to find patients receiving abdominal/pelvicComputed Tomography (CT) scans at the University of NorthCarolina Health Care System (UNC HCS) between January
Correspondence to
: Laurence E. Dahners (T: 1-919-966-3340;F: 1-919-966-6730; E-mail: led@med.unc.edu)
ß
2011 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
 JOURNAL OF ORTHOPAEDIC RESEARCH NOVEMBER 2011
1719
 
1, 2000 to April 31, 2009. The researchers collected 246 par-ticipants for the study by randomly selecting 21
Æ
2 maleand 21
Æ
2 female patients in each 10-year age group from20 to 79 (i.e., 20 males and 20 females who were 20–29, 20males and 20 females who were 30–39, etc.).
Procedure (Methods)
The study was a retrospective review of CT radiographs of the abdomen/pelvis. The IMPAX Picture Archiving Commu-nication System (PACS) (AGFA HealthCare, Greenville, SC)was used to digitally retrieve the radiographs and makemeasurements. All of the distances were measured by using the calipers provided by the PACS software. The softwareenables straight-line measurements with an accuracy of 0.01 mm. Figure 1 diagrams the measurements made foreach subject, which included the distances between the out-ermost edges of the greater trochanters and of the iliacwings, and the greatest width of the pelvic inlet. The diame-ter of the femoral head was measured on the axial cut CT forwhich the AP diameter was the greatest. The inter-femoralhead distance (center to center) was calculated by adding 2
Â
the calculated radius of the femoral head to the minimumdistance between the surfaces of the femoral. This methodeliminated possible errors in determining the location of thecenters of the femoral heads. The greatest height and widthof the L4 vertebra were also measured at its midpoint.
Statistical Methods
Data analysis for this project was performed using linearregression. Each measurement outcome was separated bygender and plotted against patient age. Linear regressionlines were fit to each gender group, allowing quantitativeestimation of the change in measurement over time.
p
-Valueswere then calculated for each line, giving an estimate of thestatistical significance of the relationship seen.
Source of Funding
There was no external funding source, and funding did notplay a role in the investigation.
RESULTS
Our results are displayed in Table 1 and graphically inFigures 2–8 (with triangles representing 10-yearmeans).The mean value for trochanteric width for allpatients was 295.3 mm, with females having a meanvalue of 303.5 mm and males 286.8 mm. The mean
Figure 1.
Measurements taken on pelvis and vertebra.
Figure 2.
Width between trochanters versus age.
Table 1.
Average Pelvic Measurements and Effect Sizes Average(cm)Effect(Slope) mm/Yearof AgeTotal Increase Age 20–80 (mm)
p
-ValueTrochanter width 29.53 0.333 20
<
0.0001Males 30.35 0.366 22 0.0001Females 28.68 0.275 17 0.0012Iliac wing width 25.44 0.371 22
<
0.0001 Average pelvic inlet width versus age 9.89 0.026 1.6 0.536 Average femoral head diameter versus age 4.42 0.055 3.3 0.0005Inter-femoral head distance versus age 16.73 0.114 6.8 0.0015L4 vertebral height versus age 3.00 0.014 0.9 0.187L4 vertebral width versus age 4.22 0.062 3.7 0.0003
1720
BERGER ET AL.
 JOURNAL OF ORTHOPAEDIC RESEARCH NOVEMBER 2011
 
value for iliac wing width for all patients was272.6 mm, with females having a mean value of 276.8 mm and males 268.1 mm.The association between age and pelvic widening was significant. The trochanteric width increased0.333 mm per year (
 p
<
0.0001) or a total of 20 mmfrom age 20 to 80. The effect was (0.366 mm/year,
 p
¼
0.0001) in males and in females (0.275 mm/year,
 p
¼
0.0012).The iliac wing width increased 0.371 mm/year of age (
 p
<
0.0002) or 22 mm from age 20 to 80. In menthe effect was 0.398 mm/year of age (
 p
<
0.0001) whilein females the effect was 0.330 mm/year of age(
 p
¼
0.0003). While the width of the pelvic inlet did not signifi-cantly increase, the distance between the femoralheads and the femoral head diameters did. Thedistance between the centers of the femoral headsincreased 0.114 mm/year of age (
 p
¼
0.0015) or6.84 mm from age 20 to 80. Men had a greaterincrease in this distance of 0.126 mm/year of age(
 p
¼
0.0136) compared to women (0.050 mm/year of age,
p
¼
0.0486).The diameter of the femoral heads also increased0.055 mm/year of age (
 p
¼
0.0005) or a total of 3.3 mmbetween the ages of 20 and 80. The effect was higherin males (0.058 mm/year of age,
p
¼
0.0001) thanfemales (0.043 mm/year of age,
p
¼
0.0045).The L4 vertebral height did not increase in a signif-icant manner, but the L4 width did increase signifi-cantly. The L4 width increased 0.052 mm/year of age(
 p
¼
0.0003). The women had a greater increase in L4width of 0.071 mm/year of age (
 p
<
0.0001) comparedto men who had an increase of 0.044 mm/year of age(
 p
¼
0.0313).
DISCUSSION
These results continue to surprise us. They do supportour unexpected earlier finding that pelvic and verte-bral dimensions enlarge in width after skeletal matu-rity and the cessation of longitudinal growth. The useof CT data has allowed us to discard the hypothesisthat our earlier results were due to magnificationerrors brought on by increased obesity in oldersubjects. However, though the lack of an increase L4vertebral height would appear to dismiss the hypothe-sis that we do not have a selection bias with largersubjects in our older groups, the femoral head data,which we expected would also show no increase(because there is no known mechanism for
Figure 6.
Diameter of femoral heads versus age.
Figure 5.
Interfemoral head distance versus age.
Figure 4.
Width at pelvic inlet versus age.
Figure 3.
Width between iliac crests versus age.SURPRISING EVIDENCE OF PELVIC GROWTH
1721
 JOURNAL OF ORTHOPAEDIC RESEARCH NOVEMBER 2011

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