Accepted Manuscript

Title: Can osteophytes be used as age at death estimators?

Testing correlations in skeletonized human remains with
known age-at-death

Authors: Francisca Alves-Cardoso, Sandra Assis

PII: S0379-0738(18)30192-0
DOI: https://doi.org/10.1016/j.forsciint.2018.04.034
Reference: FSI 9273

To appear in: FSI

Received date: 27-2-2017

Revised date: 7-4-2018
Accepted date: 16-4-2018

Please cite this article as: Francisca Alves-Cardoso, Sandra Assis, Can
osteophytes be used as age at death estimators? Testing correlations in
skeletonized human remains with known age-at-death, Forensic Science
International https://doi.org/10.1016/j.forsciint.2018.04.034

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Can osteophytes be used as age at death estimators? Testing correlations in skeletonized
human remains with known age-at-death

Abbreviated title: Testing osteophytes and age-at-death correlations

Francisca Alves-Cardoso1,2, Sandra Assis1,2

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LABOH – Laboratório de Antropologia Biológica e Osteologia Humana, CRIA/FCSH,
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Universidade NOVA de Lisboa, Portugal;
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CRIA – Centro em Rede de Investigação em Antropologia, Universidade NOVA de Lisboa,

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1200-069 Lisboa, Portugal.

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Please send proof to: Francisca Alves-Cardoso, CRIA – Centro em Rede de Investigação em

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Antropologia, Faculty of Human and Social Sciences, NOVA University, Edifício ID, FCSH-
Nova, Av. Berna, 26, sala 3.09, 1069-061 Lisboa, Portugal; Telephone: +351 217908300.
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Present/permanent address:
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CRIA – Centre for Research in Anthropology, Faculdade de Ciências Sociais e Humanas,
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Universidade Nova de Lisboa, Portugal 1200-069.

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Highlights

• A relationship between age and degenerative joint changes have been reported.
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• A sample of 604 adult individuals and 16 joints were examined to test correlations.
• Significant results were found between age-at-death and osteophytes.
• Low to moderate correlations were obtained for joints and for both sexes.
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• Osteophytes are problematic as age indicator due to its multifactorial origin.

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Abstract

Age-at-death estimation is one of the major challenges when establishing an adult skeleton
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biological profile. The presence of degenerative joint changes – e.g. osteophytes – has been
regarded as a good postmaturity age indicator. This study assessed if a clear relationship
between age and osteophytes exists. To accomplish this goal, a total of 16 joint surfaces, from
the shoulder, elbow, wrist, hip, knee, and ankle, were examined in 604 adult individuals, of
both sexes from two Portuguese Identified collections. Individuals had between 20 and 98
year old at death.
Statistically significant results were found between age-at-death and degrees of severity of
osteophytes throughout all the articular surfaces analyzed (p>0.001). However, the strength of
the correlation varies from moderate to low in the majority of the joints, for both sexes. The
only strong correlation effects (r=0.567 in females and r=0.552 in males) were found
associated with the left and right glenoid cavity in females and males respectively. More
noticeable changes were consistently found in association with older individuals (>62years
old).

Results indicate that significant relationships exist between age and the presence of
osteophytes in the joint margins. However, correlation effects were low to moderate in most
cases, therefore the use of osteophytes to predict age-at-death is not without significant error
of interpretation.

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Keywords: Adult skeletons; joints; osteophytes; biological age; identified collections

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Introduction

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Age-at-death estimation is a pivotal step in every forensic and bioarchaeological study.
However, while age-at-death assessment in skeletonized remains of non-adults is regarded as
fairly accurate, substantial limitations exist in assessing age-at-death in adult remains,

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especially those of advanced ages [1]. Most methods for age-at-death estimation in non-adults
rely on skeletal parameters – and teeth - development and maturation (e.g. formation of tooth
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crowns and roots, appearance and union of bony epiphyses, and diaphyseal length). Those
criteria rely on the timings and rates of growth which are genetically determined and less
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susceptible to external influences [1-5]. In adult remains, signs of skeletal senescence –
nowadays credited as environmental sensitive - have been assigned as key-point factors for
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biological age estimation [2,4]. Accordingly, and in the last decades, several macroscopic
aging techniques based on suture closure, as well as on the metamorphosis of the sternal end
of the 4th rib, symphyseal surface of the pubis (os coxae) and auricular surface of the ilium
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(os coxae) were created and tested in various human skeletal assemblages composed of
identified individuals [e.g. 6-21]. Despite all available methods, the problematic of age-at-
death estimation in mature skeletonized remains continues to be one of the issues most
frequently debated in forensic anthropology literature [for a detail review see, e.g. 22-27]. A
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multifactorial approach combining distinct methods is normally credited as more precise than
single approaches, e.g. based on a single morphological change and/or trait [25]. In this scope,
other skeletal traits, such as osteoarthritis have been used as complementary postmaturity age
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indicators in conjunction with the most conventional methods [25, 28-29]. In fact,
degenerative joint changes (of which osteophytes are major reference and used to assess
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osteoarthritis – OA) have been regarded as valid age-at-death estimators since studies have
shown the existence of a significant association with age [25]. For instance, Giles and
Marquez-Grant [30] studying an identified skeletal sample found that osteoarthritic markers
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are strongly correlated with age, which stresses its usefulness as complimentary indicators to
assist adult age-at-death estimation in forensic contexts.

The relationship between age and degenerative joint changes derives, in part, from the fact
that age has been clinically considered as a major contributing factor in the onset of OA, and a
reference in the disease epidemiological studies [31-33]. Although OA is defined as a disease
of middle age to late adulthood, i.e. essentially age related, the likelihood of its development
is also associated with other systemic factors (metabolic, hormonal, genetic, and sex-related),
local biomechanical factors (such as mechanical workload), body mass index, joint
morphology, and other pathologies [34-43].

One of the bony changes most frequently observed in the pathogenesis of OA are osteophytes
[44,45]. Osteophytes can be defined as a “fibrocartilage-caped bony outgrowth” that develop
in the periosteum that covers the bone at the contact point between cartilage and bone [45:
237]. It is unclear if osteophytes are a functional adaptation or a pathological phenomenon
associated with other joint changes [45,46]. In certain bone joints – i.e. patellofemoral joint,
osteophytes are considered sensitive radiographic features for detection of articular cartilage
degeneration. Other features such as joint space narrowing, subchondral sclerosis and
subchondral cysts rarely occurred without osteophyte formation, making those a key feature
in the diagnose of OA in patellofemoral joint [47]. In these cases, however, it is difficult to

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separate aging from OA due to its high correlation [45]. Some authors regard osteophytes as a
repairing response; that is, a reaction of bone and cartilage to abnormal mechanical loading,

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aiming to restore a damaged joint and ensure functional stability [31]. For example, Felson
and colleagues [46] found a correlation between the development of osteophytes in the knee

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and limb malalignment. In other clinical studies, osteophytes are interpreted as merely age-
related, and not directly associated with OA. This was argued in cases when osteophytes

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appear in the absence of other bony changes, i.e., subchondral cysts or subchondral sclerosis
[45,48-52]. In bioarchaeology, osteophytes tend to be used simultaneously as age-at-death
indicators, complementing other methodologies of age assessment, and as related with
degenerative joint diseases. In forensic analysis, some studies have documented a general

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pattern of osteophyte development and/or OA associated with age, validating its use as age-at-
death assessment criteria [30, 53-55]. This paper aims to explore the correlation between
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osteophytes and age-at-death in skeletonized human remains. It targets exploring the
correlation between osteophytes and age-at-death, since the former is often overly used to
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assess age in human remains in contexts where sex, age, occupation and causes of death are
unknown and cannot be taken into consideration. Whereas previous studies have
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circumscribed their analysis to particular joints of the skeleton, such as those of vertebral
column [53, 54], shoulder [55], or shoulder, hip and knee [30], this study will test the
hypothesis that the development of osteophytes is correlated with age, and ultimately aging, in
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15 joint surfaces of the appendicular skeleton. The study of a larger set of appendicular joints
(less explored in similar studies) will provide a better picture of the “aging” effect in the
skeleton. This research is relevant for studying skeletonized human remains recovered from
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archaeological, forensic and other contexts: it will either validate the use of osteophytes as
age-at-death indictors, or highlight limitations to its use. Therefore, a further goal of this paper
it so explore the limitations of using degenerative joint changes, namely osteophytes, as age-
at-death indicators.
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Material and Methods

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A sample composed of 603 adult individuals, of both sexes (males, n=300; females, n=303),
was selected from two Portuguese Human Identified Collections (HIC): the Lisbon Luis
Lopes Skeletal collection (LLSC = 304 skeletons, 151 males and 153 females) and the
Coimbra Identified Skeletal collection (CISC = 299 skeletons, 149 males and 150 females).
Individuals were selected from these HIC to allow controlling for age-at-death and sex, since
individuals have known biographic records that include sex, age-at-death, cause-of-death,
occupation, amongst others. The individuals were born between 1822 and 1935, and died
between 1891 and 1965. There is a significant overlap concerning year of birth between
individuals of both collections, whilst a slight difference exists regarding year of death
(Figure 1). The CISC individuals died between 1823 and 1936, and the LLSC individuals died
between the years 1891 and 1965. Further information with regard to the history and
composition of the HIC used in this study can be found in Rocha [56] and Cardoso [57]. The
age-at-death of the individuals selected ranged between 20 – 98 years old. With regard to the
sample composition, it should be mentioned that male and female age-at-death had
statistically significant differences (p<0,001), with the mean age-at-death of women being
notably higher (mean age = 56 years old) when compared with males (mean age = 49,78 year-
old). Due to this bias, and to control for morphological sex-related differences of joints, male
and females data were analyzed separately.

The osteophytes were originally recorded following the recording protocol proposed by
Buikstra and Ubelaker [58]. The recording protocol used the term marginal lipping, rather

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than osteophytes, although they are equivalent. Osteophytes were graded according to their
expression (as described in the protocol), with the classification ranging from barely

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discernible to joint ankylosis [58: 115]. This expression categorizes the overall growth of the
osteophytes implying that a bigger bone growth has taken longer to form – it is not intended

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to associate bone growth with severity of lesion. During data collection skeletons exhibiting
abnormal bone growth and/or remodeling were excluded after careful examination and

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whenever the changes were diagnosed as probably associated with other pathologies such as
Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier’s disease, other
diseases that could contribute to extra-spinal enthesopathy formation, as well as trauma
amongst other cases. Joints poorly preserved and with considerable taphonomical changes

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which prevented the evaluation of osteophytes were also excluded. In total 15 joint surfaces
which compose the major skeletal joints, e.g. the shoulder, elbow, wrist, hip, knee, and ankle
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were examined. Left and right sides were assessed separately.
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The statistical analysis comprised the frequencies and percentages of the different variables
observed, as well as descriptive statistics with mean, standard deviation and maximum and
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minimum values observed. The Wilcoxon Signed-rank test procedure was used for pairwise
comparisons. The Kendall's tau_b statistical test was used to test correlations between
variables due to sample size variation, with implications in the normal distribution of
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variables. Boxplots were used to summarize descriptive statistics of osteophytes, considering

age and clustering individuals according to sex.

Results
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The distribution of lesions by joint, sex and side can be consulted in Table 1. Osteophytes
were found in all joint analysed, being more frequent in the acetabulum (left: 85.6%, 506/591;
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right: 87.2%, 520/596) and glenoid cavity (left: 61.8%, 362/586; right: 60.8%, 354/582). The
fibula distal end (ankle joint) exhibited the low frequency of osteophytes for both sides (left:
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5.5%, 32/582; right: 5%, 29/581). When testing bilateral asymmetry statistical significance
was found on the following anatomical regions: scapula acromion surface (p<0.001), humerus
distal end (p=0.029), ulna proximal end (p=0.001), ulna distal end (p<0.001), femur proximal
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end (p=0.004), femur distal end (p=0.006) and tibia distal end (p<0.001).

With regard to the distribution of osteophytes according to sex, the frequency of females
exhibited this bony change was higher when compared with males. In females, the joints most
frequently affected by osteophytes were the clavicle acromion surface (left: 61,8%, 81/131)
and the radius proximal end (left: 60%, 54/90; right: 59,6%, 56/94), whereas in males, it was
the fibula distal end (left: 62,5%, 20/32; right: 58,6%, 17/29). Bilateral asymmetry testing
detected a clear right side dominance of lesions for both females and males. The only sites
where a left dominance was detected were on the female humerus distal end (p=0.038).
The joint surfaces with the high mean values of severity of lesion were the acetabulum (left:
mean=1.470, N=591; right: mean=1.490, N=596), the glenoid cavity (left: mean=0.911,
N=586; right: mean=0.928, N=582), patella (left: mean=0.766, N=539; right: mean=0.792;
N=530), femur proximal end (left: mean=0.725, N=589; right: mean=0.793; N=590), and
femur distal end (left: mean=0.711, N=595; right: mean=0.787, N=595) (Table 1). In these
cases, however, only the mean values obtained for the femur distal end (left: p=0.000; right:
p<0,001), and patella (left: p=0.006; right: p=0.001) were found to be statistically significant.
In all cases women‘s mean value of lesion was higher than the one found in men.

Statistically significant results were found between age-at-death and overall degree of
osteophytes throughout all the articular surfaces analyzed (p>0.001). On average, individuals
with lesions were significantly older than individuals without osteophytes. In fact, the

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directionality of the association was noticed as positive in all cases, i.e. as aged increased so
did the degree of osteophytes. More noticeable changes, classified as “sharp ridge” and

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“extensive spicule” according to Buisktra and Ubelaker [58] recording protocol, were also
consistently found in association with older individuals. The mean age-at-death associated
with these lesions was of ≥ 62 years of age in all articular facets observed. The Kendall‘s

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tau_b correlation statistical test corroborated the presence of a positive relationship between

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age and osteophytes (Table 2). However, the strength of the correlation varied from moderate
(0.3-0.5) to weak (0.1-0.3) in the majority of the joints, for both sexes. The only strong
correlation effects (r >0.500) were found associated with the left and right glenoid cavity and
acetabulum in females and males.

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The boxplot data distribution highlights the positive association of osteophytes and age,
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showing that the more pronounced osteophytes, classified as “sharp ridge” or “extensive
spicule”, cluster with older age-at-death. However, this data distribution also shows a
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manifest variability on the distribution of the osteophytes per age. For example, “sharp
ridges” changes were also found in individuals on their early thirtieths; and some older
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individuals had not major changes to be accounted for. There are also several outliers that are
illustrative of the uniqueness of individuals to develop osteophytes (see discussion below).
This is both valid when statistically significant results achieved strong positive correlations, as
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well as when the correlation strength is weak as shown in the boxplots (Figure 2): the figure
exemplifies some of the articular surfaces were strong to weak correlations were found,
illustrating the abovementioned, i.e. the evident variability osteophytes presence per age,
which was the overall pattern found in all articular sites evaluated (please consult the
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supplementary data to view all osteophytes distribution per articular surfaces analyzed).
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Discussion and Conclusions

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Age-at-death estimation is one of the major challenges when building an adult skeleton
biological profile, consequently a multi-methodological approach is normally recommended
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for assessing biological age. The presence of degenerative joint changes constitutes one of the
indicators of bone senescence broadly considered in many bioarchaeological studies.
Osteophytes is viewed as a form of degenerative bone change of joints frequently observed in
skeletonized human remains [59,60]. In clinical settings, osteophytes are also a common
radiographic manifestation mostly associated with osteoarthritis (OA), and recurrent in older
individuals [32,61]. The relationship between age and osteophytes is well-known; however,
this does not mean that age directly causes osteophytes, nor OA as that matter, or that the
bony changes observed in joints only manifest in older individuals [61]: has shown in the
current research. As a disease, OA is a multifactorial - it develops from the interplay between
systemic (e.g. age, sex, genetics, hormones, nutrition, and bone density) and mechanical
factors (potentiated by obesity, muscle weakness, injury and joint deformity) [31,32]. It is the
interaction between these risk factors, namely age, that determine which joint is affected and
the severity of the changes observed [61]. Although clinical data has shown that osteophyte
formation is an integral component of OA [45,51 only to name a few], osteophytes have
consistently been ruled as primarily correlated with biological age in bioarchaeological
studies [59,62,63]. The present study showed that the age-forming approach to osteophytes
may be an oversimplification. Despite the significant relationship observed between age-at-
death and osteophytes in all joints analyzed, the correlation effects were weak to moderate in
most cases. Furthermore, a wide variability of the distribution of osteophytes per joint facet
was found. Also, and most importantly, having or not having bone changes is not age specific
in the sense that young individuals may exhibits changes, and older individuals not: this is

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particularly true in the case of the early degree of osteophytes, here classified as “barely
discernible”. Barely osteophytes were found in individuals in their second decade of life, and

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sharply ridged osteophytes in individuals as young as 30 years old. Most important also is that
fact that it is impossible to assess the timing of appearance and development of the bone

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change: we know only its end result at time of death. It is also unknown how long it takes to
bone to develop the many osteophytes formation analyzed in joints. There is never one form.

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Therefore the use of osteophytes to predict age-at-death is not without error and may bias an
accurate estimation of age. Therefore, and although the results here achieved support the
initial hypothesis that osteophytes are correlated with age-at-death, the level of significance
and correlation is not without cautionary interpretation.
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One could argue that the outliers (see boxplots Figure 2) identified in the current sample may
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be influencing the absence of stronger correlations between osteophytes and age-at-death.
This is a valid observation and it raises one of the most important issues when assessing bones
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changes in human skeletal remains, which is: any interpretation of bone changes needs to
consider a differential diagnosis as to its possible etiology. With regards to osteophytes, and
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as pointed out previously, their exact etiology is not fully understood [46]. For example, some
researchers argue that osteophytes develop to restore joint stability after abnormal
biomechanical stress [31]. After a tear of the anterior cruciate ligament, osteophytes tend to
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develop anteriorly and posteriorly to stabilize the knee joint [46]. Felson and colleagues [46]
found that osteophytes are more frequent in areas of the knee joint that show malalignments.
In this specific case joint morphology, its alignment (in this specific case of the knee) as well
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as limb length inequality are considered determinants of progression in hip and knee bone
changes diagnosed as OA [31,46,64-70]. Joint specific anatomy may also be a major factor as
hinge joints (knee) and ball-and-socket joints (hip) may cope differently with risk factors
associated with OA, such as mechanical loading and/or overweight [43]. In these cases, both
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systemic and local factors seem to operate in a joint-specific way and determine whether the
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bone response will provide protection or end in degeneration [31]. Therefore, in the present
study, the variability in the expression of osteophytes may not be exclusively age-related, but
the product of individual and/ or local factor, some of them related with the morphology of
joints, alignment of limbs and local damage: had it been solely age related, the outliners
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would be non-existent. Hence, the justification not to exclude outliers from the analysis since
they are relevant on the understanding of population patterns age-related degenerative bone
changes without overlooking, nor excluding contributing factors of bone change presence.
The above mentioned further reinforces the need to rather than blindly use degenerative
changes to infer age, a thorough etiological assessment needs to be implemented when
assessing such changes at an individual level. Only after such exercise can one determine the
validity of using (in this case specific) osteophytes to infer age–at-death; and even in these
situations, case studies should be treated independently to account for bone/individual
variability and predisposition.

The present study has also showed that osteophytes were more frequent, and more expressive
in some of the joints surfaces of the hip, knee, and shoulder. These results concur with the
pattern reported in the literature that describes osteophytes as a common finding in the knee
and hip joints when compared with the ankle joint [59]. With regards to bilateral asymmetry,
the strong right side dominance was another consistent finding. While these results were
predictable for the joints of the upper limb - based on the fact that the majority of people are
right-handed [71,72] and that the overuse of right-hand side joints may imply more
degenerative changes - it was not for the lower limb joints. Once again, these differences
cannot be exclusively explained by age, but rather by a combination of different individual

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and joint specific risk factors such as articulation geomorphology and tissue composition. On
the other hand, the high frequency of osteophytes found in females individuals are probably

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age-related and an artifact of the sample composition. As mentioned before, the mean age-at-
death of women in this study sample was notably higher when compared with those of men.

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Additionally, the included association between osteophytes, age and females is known to exist
in epidemiological studies, as many degenerative changes of the knee joint – osteophytes

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included – are more frequent in women, especially in those individuals who died in the
seventh and eighth decades of life [31]. Nevertheless, other etiologies cannot be undermined.
For example, sex-specific differences between males and females may be associated with
differences in the joint morphology [73-75]. Cicuttini and colleagues [73] showed that on

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average, males had significantly larger femoral and patella cartilage volumes than females,
independent of age, body size and bone size. The authors also acknowledge the need for more
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insight perspectives in the sex-specific studies regarding cartilage development [73]. The fact
that joints ‘morphology may have a part to play in the development of degenerative joint
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lesions, or susceptibility to joint diseases [73,76,77], is another issue to be incorporated into
the bioarchaeological analysis.
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In conclusion, this study showed that age seems to play an important role in the development
of osteophytes. However, the differences found in the distribution and severity of osteophytes
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within and between joints hampers its readily application as a reliable age indicator. The same
results were found by other authors [78]. Moreover, it overlooks the overall evolution of the
changes in an individual, and population at large, and the many contributors in joint
development such as occupation. It tends to forget the fact that different joints may display
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different changes, as well as degrees of changes depending on as many factors as sex, age,
genetics, morphology, body weight and others. It is important to bare in mind that
degenerative changes are multifactorial. If used as age assessors they need to be used as
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complement to other biological indicators of age, and always referencing to the individual
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under analysis.
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Funding: This work was funded by the Fundação para a Ciência e a Tecnologia (FCT,
Portugal) and the Investigator Program supported by the European Commission ESF and
POPH [grant number IF/00127/2014] - F. Alves-Cardoso; and the FCT Investigador
Exploratory Project [grant number IF/00127/2014/CP1233/CT0003] - Sandra Assis.
Acknowledgments

The authors would like to thank the Lisbon Museum of Natural History, Portugal, and the
Anthropological Museum of the Department of Anthropology, at Coimbra University
(Portugal) for access to the Human Identified Skeletal collection. F. Alves-Cardoso would
like to extend her thank to Professor Charlotte Roberts, from Durham University, UK, for her
support throughout our Ph.D. which was used as basis for this research.

This work was funded by the Fundação para a Ciência e a Tecnologia (FCT, Portugal) and the
Investigator Program supported by the European Commission ESF and POPH [grant number
IF/00127/2014] - F. Alves-Cardoso; and the FCT Investigador Exploratory Project [grant
number IF/00127/2014/CP1233/CT0003] - Sandra Assis.

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This research was presented as a poster entitled Is a statistical significant result sufficient to

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estimate age? Testing marginal lipping and age-at-death correlation, at the 18th Annual
Conference of the British Association for Biological Anthropology and Osteoarchaeology
(BABAO), that took place at University of Kent, UK, between the 9th and 11th of September

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with the title. Alves-Cardoso participation at BABAO conference was supported by the

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Centro em Rede de Investigação em Antropologia UID/ANT/04038/2013.

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N
A
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Figure 1. Distribution of the individuals, per collection, according to decades of birth and

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death. LLSC – Luis Lopes Skeletal Collections; CISC – Coimbra Identified Skeletal

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N
A
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ED
E PT
CC
A
Collection.

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N
A
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ED
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Figure 2. Cases exemplifying osteophytes distribution according to sex and age-at-death with
strong (on top), moderate (middle) and bottom Kendall's tau-b correlation.
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Table 1. Sum-up table showing: (a) descriptive statistics of the degenerative bones changes observed, per articular surface, according to the overall
sample, sex and degree of severity; (b) bilateral asymmetry of degenerative bony changes per articular surface (overall sample) and according to
sex.

U
Osteophytes

N
Distribution of bone changes Bilateral asymmetry Distribution of bone changes (by sex)3 Bilateral asymmetry Degree of lesions (by sex)4
Bone: joints Side (overall sample)1 (overall sample)2 (by sex)
Females Males Females (Mean score values) Males (Mean score values)

A
% na/Nb Z p % na/Nb % na/Nb Z p N Mean S.D. N Mean S.D.
Scapula: acromion Left 28.3% 139/491 -4.056 <0.001 54% 75/139 46% 64/139 -1.07 0.287 250 0.432 0.732 241 0.344 0.627
articular surface Right 35.1% 171/487 52.6% 90/171 47.4% 81/171 -1.42 0.155 240 0.600 0.886 247 0.466 0.748

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Clavicle: Left 27.98% 131/469 -1.424 0.157 61.8% 81/131 38.2% 50/131 -2.54 0.010 248 0.472 0.747 221 0.308 0.629
acromion articular Right 28.3% 134/475 53% 71/134 47% 63/134 -0.66 0.495 239 0.427 0.740 236 0.398 0.751
surface
Shoulder joint
Left 61.8% ED 362/586 -1.020 0.314 52.20% 189/362 47.80% 173/362 -1.25 0.211 296 0.956 0.853 290 0.866 0.827
Glenoid cavity
Right 60.8% 354/582 51.40% 182/354 48.60% 172/354 -0.38 0.709 293 0.945 0.890 289 0.910 0.869
Left 41.1% 236/574 -1.919 0.062 57.60% 136/236 42.40% 100/236 -2.87 0.004 289 0.626 0.767 285 0.460 0.699
Humeral head
Right 45.4% 262/577 57.30% 150/262 42.70% 112/262 -3.48 <0.001 287 0.686 0.775 290 0.479 0.687
Elbow joint
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Humerus distal Left 33.3% 188/565 -2.212 0.029 55.30% 104/188 44.70% 84/188 -1.71 0.088 286 0.476 0.714 279 0.373 0.633
end Right 41% 233/568 55.80% 130/233 44.20% 103/233 -2.54 0.011 283 0.562 0.683 285 0.428 0.638
Radius proximal Left 16.4% 90/549 -0.270 0.788 60.00% 54/90 40.00% 36/90 -2.26 0.024 274 0.321 0.731 275 0.171 0.479
end Right 17.6% 94/534 59.60% 56/94 40.40% 38/94 -2.05 0.041 267 0.326 0.732 267 0.213 0.591
E

Left 43.8% 252/576 -3.453 0.001 52.40% 132/252 47.60% 120/252 -1.72 0.085 287 0.672 0.826 289 0.536 0.712
Ulna proximal end
Right 50% 290/580 51.00% 148/290 49.00% 142/290 -1.14 0.257 290 0.752 0.840 290 0.662 0.778
CC

Wrist joint
Left 28.1% 160/570 -0.375 0.696 51.90% 83/160 48.10% 77/160 -0.79 0.428 279 0.355 0.605 291 0.326 0.605
Radius distal end Right 28.6% 163/570 88/163 75/163 285 0.358 0.586 285 0.333 0.620
54.00% 46.00% -1.00 0.317
Left 15.8% 84/533 -3.867 <0.001 47.60% 40/84 52.40% 44/84 -0.22 0.833 260 0.227 0.588 273 0.234 0.591
A

Ulna distal end

Right 23.6% 127/539 49.60% 63/127 50.40% 64/127 -0.11 0.909 262 0.317 0.639 277 0.325 0.661
Hip joint
Left 85.6% 506/591 -0.794 0.388 51.20% 259/506 48.80% 247/506 -0.91 0.365 299 1.502 0.825 292 1.438 0.833
Acetabulum
Right 87.2% 520/596 50.60% 263/520 49.40% 257/520 -1.37 0.170 301 1.532 0.818 295 1.447 0.789
Left 55.3% 326/589 -2.875 0.004 53.10% 173/326 46.90% 153/326 -1.25 0.210 296 0.753 0.734 293 0.696 0.776
Femoral head
Right 59% 348/590 51.70% 180/348 48.30% 168/348 -1.34 0.181 294 0.837 0.793 296 0.750 0.767
Knee joint
Left 53.8% 290/539 -1.941 0.049 54.10% 157/290 45.90% 133/290 -2.74 0.006 268 0.869 0.862 271 0.664 0.771
Patella
Right 54.2% 287/530 55.70% 160/287 44.30% 127/287 -3.19 0.001 264 0.909 0.876 266 0.677 0.815
Left 49.7% 296/595 -2.743 0.006 54.70% 162/296 45.30% 134/296 -3.61 0.000 299 0.860 0.941 296 0.561 0.706
Femur distal end
Right 53.9% 321/595 55.80% 179/321 44.20% 142/321 -4.02 <0.001 299 0.943 0.948 296 0.628 0.766
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Tibia proximal Left 39.3% 231/588 -1.643 0.109 57.10% 132/231 42.90% 99/231 -3.45 0.001 296 0.703 0.871 292 0.445 0.684
end Right 39.7% 234/590 55.60% 130/234 44.40% 104/234 -2.48 0.013 298 0.711 0.923 292 0.514 0.780
Ankle joint

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Left 29% 173/596 -4.128 <0.001 49.10% 85/173 50.90% 88/173 -0.29 0.777 300 0.313 0.525 296 0.318 0.508
Tibia distal end
Right 35.7% 212/594 46.20% 98/212 53.80% 114/212 -1.28 0.208 297 0.384 0.588 297 0.438 0.596
Left 5.5% 32/582 -0.493 0.750 37.50% 12/32 62.50% 20/32 -1.48 0.133 292 0.041 0.199 290 0.072 0.273

N
Fibula distal end
Right 5% 29/581 41.40% 12/29 58.60% 17/29 -0.96 0.366 291 0.045 0.223 290 0.062 0.256
1
a - number of cases with lesion; b - total number of cases where observation was possible.

A
2
Bold p-values represent statistical significant values (according to the Monte Carlo significance test. 2-tailed. 99% confidence interval).
3
a - number of females with osteophytes; b- total number of cases with lesion. Bolded areas represent cases of statistical significance according to Chi-square

M
statistical test. The p-value was set at 0.05. exact two-tailed.
4
Reference to total number of cases observed (N), average of the degree of lesions (Mean) and Standard deviation (S.D.).
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Table 2. Kendall's tau_b statistical test results.

Shoulder Elbow Wrist

U
Upper Limb Humerus Humerus distal Radius proximal Ulna proximal Radius distal
Glenoid Cavity Ulna distal end

N
proximal end end end end end

Female:Age*Osteophytes Left Right Left Right Left Right Left Right Left Right Left Right Left Right

A
** **
Correlation Coefficient 0.567 0.552 0.457** 0.493** 0.388** 0.408** 0.302** 0.344** 0.385** 0.453** 0.382** 0.436** 0.322** 0.359**
Sig. (2-tailed) <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001

M
N 296 293 289 287 286 283 274 267 287 290 279 285 260 262
Male:Age*Osteophytes
Correlation Coefficient 0.543** 0.552** 0.374** 0.459** 0.293** 0.342** 0.146** 0.245** 0.424** 0.442** 0.278** 0.259** 0.314** 0.306**
Sig. (2-tailed)
N
<0.001
290
ED
<0.001
289
<0.001
285
<0.001
290
<0.001
279
<0.001
285
0.003
275
<0.001
267
<0.001
289
<0.001
290
<0.001
291
<0.001
285
<0.001
273
<0.001
277
Hip Knee Ankle
Lower Limb Femur proximal Femur distal Tibia proximal Fibula proximal Fibula distal
Acetabulum Patella Tibia distal end
PT
end end end end end

Female:Age*Osteophytes Left Right Left Right Left Right Left Right Left Right Left Right Left Right Left Right
** **
Correlation Coefficient 0.528 0.540 0.438** 0.475** 0.398** 0.412** 0.452** 0.496** 0.451** 0.407** 0.284** 0.277** 0.279** 0.322** 0.132** 0.152**
E

Sig. (2-tailed) <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.006 0.002
N 299 301 296 294 299 299 268 264 296 298 265 268 300 297 292 291
CC

Male:Age*Osteophytes
Correlation Coefficient 0.546** 0.519** 0.467** 0.440** 0.370** 0.373** 0.443** 0.467** 0.355** 0.372** 0.224** 0.222** 0.261** 0.253** 0.157** 0.168**
Sig. (2-tailed) <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.001 0.001
N 292 295 293 296 296 296 271 266 292 292 266 257 296 297 290 290
A