Background: For biomechanical investigations on bone or bone implants, bone quality represents an important potential bias. Several techniques for assessing bone quality have been described in the literature. This study aims to systematically summarize the methods currently available for assessing bone quality in human bone tissue, and to discuss the advantages and limitations of these techniques.Methods: A systematic review of the literature was carried out by searching the PubMed and Web of Science databases from January 2000 to April 2021. References will be screened and evaluated for eligibility by two independent reviewers as per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies must apply to bone quality assessment with imaging techniques, mechanical testing modalities, and compositional characterization. The terms used for the systematic search were: “(bone quality”. Ti,ab.) AND “(human bone specimens)”.Results: The systematic review identified 502 relevant articles in total. Sixty-eight articles met the inclusion criteria. Among them, forty-seven articles investigated several imaging modalities, including radiography, dual-energy X-ray absorptiometry (DEXA), CT-based techniques, and MRI-based methods. Nineteen articles dealt with mechanical testing approaches, including traditional testing modalities and novel indentation techniques. Nine articles reported the correlation between bone quality and compositional characterization, such as degree of bone mineralization (DBM) and organic composition. A total of 2898 human cadaveric bone specimens were included.Conclusions: Advanced techniques are playing an increasingly important role due to their multiple advantages, focusing on the assessment of bone morphology and microarchitecture. Non-invasive imaging modalities and mechanical testing techniques, as well as the assessment of bone composition, need to complement each other to provide comprehensive and ideal information on the bone quality of human bone specimens.

Complex proximal humerus fractures with metaphyseal comminution remain challenging regarding reduction and stability. In most fracture patterns the hard bone of the bicipital groove remains intact. In this case series, we describe a novel technique of hybrid double plate osteosynthesis of complex proximal humerus fractures with metaphyseal comminution. In randomly chosen shoulder specimens and synthetic bones, pilot studies for evaluation of the feasibility of the technique were performed. Between 4/2010 and 1/2012 10 patients underwent hybrid double plate osteosynthesis. Seven patients (4 male, 3 female, mean age was 50 years (range 27–73)) were available for retrospective analysis. Based on plain radiographs (anterior-posterior and axial view), the fractures were classified according to the Orthopaedic Trauma Association classification (OTA) and by descriptive means (head-split variant (HS), diaphyseal extension or comminution (DE)). Follow-up radiographs demonstrated complete fracture healing in six patients and one incomplete avascular necrosis. None of the patients sustained loss of reduction. Three patients where reoperated. The medium, not adapted, Constant score was 80 Points (58–94). Patients subjective satisfaction was graded mean 3 (range: 0–6) in the visual analog scoring system (VAS). The technique of hybrid double plate osteosynthesis using the bicipital groove as anatomic landmark may re-establish shoulder function after complex proximal humerus fractures in two dimensions. Firstly the anatomy is restored due to a proper reduction based on intraoperative landmarks. Secondly additional support by the second plate may provide a higher stability in complex fractures with metaphyseal comminution.