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OBJECTIVE The aim of this study was to investigate the incidence of postoperative radial nerve palsy (PORNP) after the surgical treatment of humeral shaft fractures through a posterior triceps splitting approach by a single surgeon's experience in a consecutive case series from a single trauma center. METHODS In this retrospective study, a total of 118 patients (82male, 36 female;mean age = 48 years, age range = 16 - 80 years)who underwent open reduction and plate fixation through posterior triceps splitting approach due to humeral shaft fractures at a level I trauma center were included. Level of the fractures was categorized as the proximal third, middle third, and distal third of the diaphysis, and then all the fractures were classified according to the AO/OTA classification system. The trend of incidence of PORNP was investigated. All the operations were performed by a single surgeon. The recovery time of PORNP was also recorded. RESULTS There were 13 cases of proximal third, 67 cases of middle third, and 38 cases of distal third fracture. Based on AO/OTA classification, there were 29 cases of A1-type, 23 cases of A2-type, 42 cases of A3-type, 17 cases of B2-type, 3 cases of B3-type, and 4 cases of C2-type fracture. The overall incidence of PORNP was 11% (13 cases). All the PORNP cases fully recovered within 10.3 ± 10.4 weeks (range = 1 - 44) with conservative treatment. Incidence of PORNP significantly decreased with increase in surgical experience (P = 0.009). The incidence of radial nerve palsy was not significantly related to the level of the fracture (P = 0.199). The incidence of radial nerve palsy was not significantly related with the fracture pattern according to AO/OTA classification (P = 0.659). CONCLUSION Evidence from this study has shown that the incidence of PORNP following the posterior triceps splitting approach for the treatment of humeral shaft fractures is significantly associated with the surgeon's experience. LEVEL OF EVIDENCE Level IV, Therapeutic Study.

Introduction: Enchondroma is a solitary, benign, intramedullary cartilaginous tumor commonly noticed in the phalanges of hands and feet with characteristic radiological features. Its occurrence in aberrant sites with atypical features lead to diagnostic dilemma. Enchondromas which are usually managed non-operatively can mimic other benign and malignant lesions, especially chondrosarcoma. Case Report: We report the case of a 31-year-old farmer who presented with long standing inconspicuous pain in his left leg which turned out to be a diaphyseal enchondroma even though it demonstrated aggressive radiological features mimicking a chondrosarcoma. Incisional biopsy was done from the scalloped areas to obtain the correct histological diagnosis. He underwent thorough curettage of the lesion and remains asymptomatic 2 years after the procedure. We attempt to discuss the differentials which the orthopedic surgeon should keep in mind for diaphyseal lesions mimicking enchondroma. Conclusion: Though classically found in metaphysis, Enchondromas are not uncommon in diaphysis of long bones. Enchondromas are generally benign, but can cause diagnostic dilemma when they present with aggressive features at rare locations and surgeons should be wary of the differentials. Despite a size of more than 6 cm and evidence of cortical erosion and intramedullary widening, the lesion could still be benign. Early biopsy will help to differentiate Enchondroma from a malignant transformation or malignant tumor. Keywords: Enchondroma, chondrosarcoma, diaphysis, multilocular, endosteal scalloping, chondroma.

We carried out a prospective randomized study to compare the clinical and radiological results of metacarpal diaphyseal fractures treated with retrograde intramedullary headless cannulated screws (IHCS) and plates. Fractures were fixed with IHCS in 34 patients (37 metacarpals) and locked miniplates in 35 patients (40 metacarpals). The mean age was 33 years (range 18–61) in the IHCS group and 32 years (range 17–68) in plate group. All patients were followed up for 1 year. All fractures in the IHCS group united but there was one nonunion in the plate group. At final follow-up, there was no significant difference between the groups in total active movement, visual analogue pain score, Disabilities of the Arm, Shoulder, and Hand score and grip strength, although the study was not sufficiently powered to exclude differences with certainty. IHCS is a safe and fast technique that is a good alternative to plate fixation in metacarpal diaphyseal fractures. Level of evidence: I

Introduction Fractures of the tibial plateau are classified by the location of the fracture line, associated capsular ligamentous injuries to the knee and can result from different types of high – or low-energy mechanisms of injury in patients of any age with different bone quality. These factors are responsible for different long-term functional outcomes and the lack of a generally accepted algorithm for diagnosis and treatment. The objective of the study was to analyze the long-term functional outcomes in patients with tibial plateau fractures treated with the Ilizarov external fixation. Material and methods The review included long-term outcomes of 59 patients with tibial plateau fractures treated with the Ilizarov external fixator. Long-term results were evaluated in 53 patients out of 59 (89.83 %) using a subjective and objective clinical assessment system.The follow-up period ranged from 2 to 4 years. Patients were requested to complete the Oxford Knee Score questionnaire used in subjective outcome. Results Knee joint function of patients with tibial plateau fractures treated with the Ilizarov external fixation were rated as satisfactory (n = 34; 64.15 %); 16 (30.19 %) and 3 (5.66 %) patients were diagnosed with mild and moderate gonarthrosis, respectively. No infection that would affect the outcome was recorded in the study group. The mean Oxford Knee Score was 43.06 ± 3.44 (SD) in Schatzker type I split fractures of the lateral femoral condyle; 40.50 ± 5.57 (SD) in Schatzker type II split fractures combined with lateral articular surface depression; 40.71 ± 4.27 (SD) in Schatzker type III depression fractures; 42.33 ± 4.22 (SD) in Schatzker type IV medial condylar fractures; 38.50 ± 7.19 (SD) in Schatzker type V bicondylar fractures and 37.50 ± 5.17 (SD) in Schatzker type VI bicondylar fractures with dissociation of the metaphysis and diaphysis. Conclusions Tibial plateau fractures can be treated with the Ilizarov external fixation and also with the use of screws at any point of time that allows closed or open reduction of the fracture to ensure the early function of the operated limb, stable bone fixation, control of the fixation stiffness at any stage of treatment facilitating good and excellent functional outcomes.

Fibrous dysplasia is a pathological condition, where normal medullary bone is replaced by fibrous tissue and small woven specules of bone. Fibrous dysplasia can occur in epiphysis, metaphysis or diaphysis. Occasionally, biopsy is necessary to establish the diagnosis. We present a review of operative treatment using the Ilizarov technique.

Objectives Measure and systematically evaluate the distribution of microhardness in the human skeleton. Methods Three fresh corpses were obtained, aged 62 (male), 45 (female), and 58 years (male). Soft tissues were removed, and all axial and unilateral appendicular bones were freshly harvested. All three skeletons were examined by X‐ray and computed tomography (CT) to exclude skeletal pathology. Only bones from donors with no known skeletal pathology were included in the study. Axial and unilateral appendicular skeleton bones from each of the three donors were obtained, except for ear ossicles, hyoid bone, tailbone, and 14 phalanges of the foot, for which samples were difficult to obtain. Precision bone specimens with a thickness of 3 mm, which were cut with a Buehler IsoMet 11‐1280‐250 low‐speed diamond saw (Buehler, USA), were obtained from all important anatomic sites in a direction perpendicular to the mechanical axis of each bone. Micro‐indentation (the Vickers hardness test) was performed on the surface of each specimen using a microhardness tester with a diamond indenter. Hardness value (HV) was computed for each indentation. Each bone specimen was divided into several regions of interest. Indentations were carefully made and computed. Then we analyzed the data to identify hardness distribution rules at different anatomic sites. Results In total, 5360 indentations were made in 1072 regions of interest in each donor. Hardness of the axial and appendicular bones were all inhomogeneous depending on the anatomic sites, but the distribution of microhardness followed certain rules. The mean hardness value ranged from 24.46 HV (HV = hardness value, kgf/mm2) for the sacrum to 53.20 HV for the shaft of the tibia. The diaphysis was harder than the metaphysis, and the proximal and distal epiphysis had lower values (8.85%– 40.39%) than the diaphysis. Among the long bone diaphyses, the tibia cortical bone (51.20 HV) was the hardest, harder than the humerus (47.25 HV), the ulna (43.26 HV), the radius (42.54 HV), and the femur (47.53 HV). However, in some anatomic sites such as the lumbar vertebra (cortical bone 32.86 HV, cancellous bone 31.25 HV), the cortical shells were sometimes not harder than the internal cancellous bones. The lumbar vertebra (32.86 HV) was harder than the cervical vertebra (28.51 HV) and the thoracic vertebra (29.01 HV). Conclusions The distribution of microhardness in the human skeleton follows certain rules. These distribution rules could be used to predict the mechanical properties of bone and progress in this field could provide data for the basis of a new three‐dimensional printing technique, which may lead to new perspectives for custom‐made implants., The data of bone microhardness, which represents bone material mechanical properties, is inhomogeneous among anatomical regions, but the distribution of microhardness follows certain rules. Hardness values could be used to predict the mechanical properties of bone; if the region has a higher hardness value it may provide better support and anchorage force for the physiological load or implants. Progress in this field could provide data for the basis of a new three‐dimensional printing technique and may lead to new perspectives for custom‐made implants.

Background The purpose of this study was to evaluate the relative contribution of the reverse shoulder arthroplasty (RSA) humeral stem length on initial implant fixation, which may contribute to the long-term success of uncemented shoulder implants. Methods Three RSA humeral components were randomly divided into the following testing groups: (1) 100% Stem length (n = 7); (2) 50% Stem length (n = 7); (3) 0% Stem length (n = 7). Each humeral stem was press-fit into twenty-one 4th Generation Osteoporotic Sawbones humeri. Torque and compressive axial load were applied to the humerus for 10,000 cycles at ±2.5 Nm and −392 N, respectively. Rotational micromotion of the implant was measured. Results Micromotion for all 3 testing groups was below the 150 µm micromotion threshold throughout testing. The overall micromotion in Group 2 was significantly larger than Group 1 (P Conclusion All stem lengths studied maintained micromotion below the 150 µm threshold, suggesting that any of these treatment groups would provide adequate initial fixation to allow bony on-growth. Clinically, stemless or short-stemmed prosthesis design offer theoretical benefits such as the degree of freedom for humeral stem placement independent of diaphysis. This study concluded that the zero-length stem will allow for this and provide adequate fixation comparable to the full-length stem. Level of Evidence Basic Science Study.

Background This study aimed to identify the characteristic radiological signs for the diagnosis of Langerhans cell histiocytosis (LCH) of the bone. Methods We retrospectively studied 82 cases of LCH with bone lesions confirmed by pathology. Clinical and radiological features of the patients were analyzed. Results A total of 64 and 18 patients had single and multiple bone lesions, respectively. With regard to LCH with single bone lesions, 37.5% (24/64) of lesions were located in the skull and presented as bone destruction with or without soft tissue mass. The correct diagnosis rate of these lesions was 60.0% (9/15) in children and adolescents, but was only 22.2% (2/9) in adults. A total of 26.5% (17/64) of the solitary lesions were found in the spine. Of these, 88.2% (15/17) were located in the vertebral body and appeared to have different degrees of collapse, and 66.7% (10/15) of these lesions were correctly diagnosed. Of the unifocal lesions, 21.8% (14/64) were located in other flat and irregular bones and manifested as osteolysis. Only 21.4% (3/14) of these cases were correctly diagnosed. In total, 14.1% (9/64) of the isolated bone LCH lesions were located in the long bones. Of these, 77.8% (7/9) were located in the diaphysis and presented as central bone destruction with or without fusiform periosteal reaction and extensive peripheral edema, of which 42.9% (3/7) were correctly diagnosed before surgery or biopsy. With regard to LCH with multiple bony destructive lesions, 71.4% (10/14) of cases in children and adolescents were correctly diagnosed; however, all four cases among adults were misdiagnosed. Conclusion In all age groups, isolated diaphyseal destruction of the long bone with fusiform periosteal reaction and extensive peripheral edema, vertebra plana of the spine, and bevelled edge of skull defects accompanied by soft tissue masses strongly suggest LCH diagnosis. Moreover, the multiple bone osteolytic destruction in children and adolescents strongly suggests LCH diagnosis. Familiarity with these typical radiological signs of LCH is necessary to decrease misdiagnoses.

While Ewing sarcoma of bone is the second most common primary osseous malignancy in childhood where it typically involves the diaphysis or metadiaphyses of long bones of skeletally immature patients, primary epiphyseal involvement of the long bone in skeletally mature patients is rare with no cases reported in the literature to our knowledge, rendering this case the first of its kind. We present the first case of primary Ewing Sarcoma of the epiphyses of the long bones in a skeletally mature 20-year-old male patient. The patient initially presented with left knee stiffness and pain that was empirically treated with non-steroidal anti-inflammatory medications. His pain progressed despite treatment. An x-ray of the left knee was obtained 5 months later demonstrating an irregular lucent lesion in the medial femoral condyle. A subsequent MRI revealed an enhancing lesion in the medial femoral condyle, and when biopsied it was consistent with Ewing sarcoma (positive for EWSR1gene rearrangement by fluorescence in situ hybridization). The lesion was resected surgically, and the patient underwent neoadjuvant chemotherapy with a good clinical outcome.

To assess the possibility of using the bird bone tissue as a recording structure, the histomorphological parameters of the bone tissue of laying hens of the lohman brown cross from the Kirov region (9 females and 1 male) aged from 1 month to 7.5 years were investigated. The comparison of the cross-sections of the humerus and femur, the phalanx of the toe and tibiotarsus of a 6-year-old individual revealed that tibiotarsus is the least susceptible to resorption. For further research in 7 individuals, this bone was divided into 3 sections (T1, T2 and T3), for each of which the description and measurement of the microstructure of the cross sections was carried out. It was revealed that the process of resorption of the periosteum begins at 2.5 years of age with the appearance of primary osteons. At the age of 3.5 years and later they penetrate into all layers of the periosteum, locating in chains between the lines of arrested growth. At 4.5 years of age, secondary osteons appear in the place of the primary ones, and areas of resorption are formed at the intersection of the Haversian and Volkmann canals. At the age of 5.5 years the medullary bone disappears from the bone cavity, rounded cavities filled with centripetal deposition of new bone tissue at the edges appear within the resorption sites. At the age of 6-7 years, bone tissue degeneration occurs, when the small cavities enlarge and merge into large resorption cavities, up to the complete resorption of the mesost. In the distal part of tibiotarsus (T3), a prolonged apposition of the layers of the periosteum and the latest resorption were recorded. The increase of the thickness of the periosteum and a decrease in the density of the osteon population was revealed by the morphometry of cross sections of the center of diaphysis. The sites of tibiotarsus where the age of females corresponds to the lines of growth layer of the periosteum were determined. The sites with additional lines of the arrested growth were demarcated. It was concluded that the periosteal layer of the domestic fowl tibiotarsus in the distal and proximal sites are suitable as a recording structure.

BACKGROUND: Treatment of tibia (upper third and diaphysis) fracture together with severe osteoarthritis (OA) poses challenge to an orthopedic surgeon. Traditionally, it is treated through three-stage surgeries, first fracture fixation followed by implant removal and finally surgery of total knee arthroplasty (TKA). Herein, we describe a novel TKA procedure using long-stemmed tibia component. This one-step technique not only addresses arthritis of the knee joint but also helps in assisting fixation of the fracture. MATERIALS AND METHODS: We reported outcomes of three female non-diabetic patients with OA who developed tibia shaft fracture following trauma. Range of motion and quadriceps strengthening exercise were initiated immediately after the procedure. X-rays anteroposterior and lateral views of the operated limbs were obtained at post-operative week-6 and week-12. We allowed the patients’ toe touch weight-bearing immediately after the surgery. The patients were progressed to full weight-bearing after confirming radiological union on the X-rays. RESULTS: At follow-up, all treated patients were able to mobilize with good range of motion of the operated knee and with union of the fracture. The American Knee society scores and WOMAC pain and stiffness scores improved significantly. CONCLUSION: This novel technique offers one-stage solution to the complex situation of osteoarthritis of the knee with associated tibia shaft fracture, thereby reducing future hospital admissions/surgeries and associated costs and complications. Further, it allows faster rehabilitation.

BACKGROUND Fractures of the proximal humerus are more common in older adults. Two options for surgical treatment of the same fractures are routinely performed — primary arthroplasty and osteosynthesis with metal fixators. Both methods are most effective in elderly patients for augmentation of the proximal humerus. For this purpose, methyl methacrylate cement or bone allo-/autografts are used. However, the incidence of unsatisfactory functional results after surgery remains high.AIM OF STUDY To develop allogeneic graft to strengthen the proximal humerus in the osteosynthesis of a comminuted fracture with a lack of bone tissue which has osteoconductive properties and capable of being a carrier of biologically active substances.MATERIAl AND METHODS The head, neck and portion of diaphysis of a fibula of a cadaver were used for a graft. The graft 6–8 cm long was formed and saturated with a collagen solution. Ten patients with 4-fragment fractures of the proximal humerus underwent surgery. X-rays and computed tomography of the operated joint were performed the day after surgery, and then, 6 weeks, 6 months, and one year after the surgery. The follow-up period ranged from 6 to 18 months.RESUlTS When evaluating osteoconductive effect in cell culture during saturation with collagen, the content cells on the surface of bone was 5–8 thousand/cm2 and 16–18 thousand/cm2 on the sample, saturated with plasma and growth factors. The studied bone grafts were biocompatible and non-toxic for fibroblast culture. On the surface of the bone graft without collagen adhesion of minimum number of cells occurred. After saturation of the graft with collagen, the adhesive activity of cells on the bone matrix increased, which indicated the presence of an osteoconductive effect. The addition of plasma saturated with growth factors promoted an increase in the number of adhered cells; therefore, the graft can be used as a carrier of biologically active substances. Postoperative X-ray didn’t reveal secondary varus displacement of the head in any patient (except for ununiformed fracture case).CONClUSION The developed graft is non-toxic, does not possess immunogenicity, has more pronounced osteoconductive properties in comparison with native bone allografts, which contributes to its colonization with cells. The use of such a graft in clinical practice makes it possible to achieve healing of the fracture and prevent secondary displacement of fragments.

Bone adapts to unaccustomed, high-impact loading but loses mechanosensitivity quickly. Short periods of military training (≤12 weeks) increase the density and size of the tibia in women. The effect of longer periods of military training, where the incidence of stress fracture is high, on tibial macrostructure and microarchitecture in women is unknown. This observational study recruited 51 women (age 19 to 30 years) at the start of 44 weeks of British Army Officer training. Tibial volumetric bone mineral density (vBMD), geometry, and microarchitecture were measured by high-resolution peripheral quantitative computed tomography (HRpQCT). Scans of the right tibial metaphysis (4% site) and diaphysis (30% site) were performed at weeks 1, 14, 28, and 44. Measures of whole-body areal bone mineral density (aBMD) were obtained using dual-energy X-ray absorptiometry (DXA). Blood samples were taken at weeks 1, 28, and 44, and were analyzed for markers of bone formation and resorption. Trabecular vBMD increased from week 1 to 44 at the 4% site (3.0%, p < .001). Cortical vBMD decreased from week 1 to 14 at the 30% site (-0.3%, p < .001). Trabecular area decreased at the 4% site (-0.4%); trabecular bone volume fraction (3.5%), cortical area (4.8%), and cortical thickness (4.0%) increased at the 4% site; and, cortical perimeter increased at the 30% site (0.5%) from week 1 to 44 (p ≤ .005). Trabecular number (3.5%) and thickness (2.1%) increased, and trabecular separation decreased (-3.1%), at the 4% site from week 1 to 44 (p < .001). Training increased failure load at the 30% site from week 1 to 44 (2.5%, p < .001). Training had no effect on aBMD or markers of bone formation or resorption. Tibial macrostructure and microarchitecture continued to adapt across 44 weeks of military training in young women. Temporal decreases in cortical density support a role of intracortical remodeling in the pathogenesis of stress fracture. © 2021 Crown copyright. Journal of Bone and Mineral Research © 2021 American Society for Bone and Mineral Research (ASBMR). This article is published with the permission of the Controller of HMSO and the Queen's Printer for Scotland.

Dysosteosclerosis is a group of sclerosing bone dysplasia characterized by short stature, increased bone fragility, osteosclerosis, and platyspondyly. It is a genetically heterogeneous disorder caused by biallelic mutations in the SLC29A3, TNFRSF11A, TCIRG1, and CSF1R genes. To date, four dysosteosclerosis patients with SLC29A3 mutations have been reported. Here, we report biallelic SLC29A3 (c.303_320dupCTACTTTGAGAGCTACCT) variant in a three-year-old girl. She had large anterior fontanelle, fracture history, short stature, camptodactyly, elbow contracture, and melanocytic nevus. Initial skeletal radiographs revealed platyspondyly, dense vertebral endplates (sandwich appearance of the vertebral bodies), diffuse sclerosis of the peripheral side of the pelvic bones, sclerosis of metaphysis and diaphysis of the long bones, metaphyseal widening, and diaphyseal cortical thickening. Mild sclerosis was also present in the skull base, maxilla, rib, scapula, and phalanges. Notably, we observed that sandwich vertebrae appearance significantly resolved and sclerosis of ribs, scapula, pelvis, and long bone metaphysis regressed over a 2.5-year period. However, platyspondyly, metaphyseal widening, and diaphyseal cortical thickening persisted. In conclusion, this study demonstrates spontaneous resolution of osteosclerosis, which was not described previously in patients with dysosteosclerosis.

Camurati-Engelmann disease (CED) is an extremely rare, sclerosing bone disorder of intramedullary ossification with only 300 reported cases worldwide. The pathogenesis is related to activating mutations in transforming growth factor beta 1, which results in bilateral, symmetric hyperostosis affecting primarily the diaphysis of long bones. Despite effective pharmacological treatment options, the diagnosis of CED is problematic owning to its rarity and variability of clinical presentation. We present a patient with known CED with advanced early hip osteoarthritis, secondary to underlying hip dysplasia, for which she underwent a successful total hip arthroplasty via a direct anterior approach with the use of bulk femoral head autograft to reconstruct her native acetabulum.

Resumo Objetivo O presente estudo visa analisar os resultados clínicos do tratamento cirúrgico das fraturas de colo do metacarpo com fixação intramedular retrógrada utilizando parafusos canulados sem cabeça (tipo Herbert). Métodos Estudo retrospectivo de 21 fraturas fechadas desviadas do colo do metacarpo em 21 pacientes operados entre abril de 2015 e novembro de 2018. Resultados A casuística incluiu 19 homens e 2 mulheres. Os mecanismos causadores do trauma foram soco, queda ao solo e acidente com veículo motorizado (n = 14, 5 e 2). Os metacarpos acometidos foram o V, III e II (n = 19, 1 e 1). As indicações cirúrgicas foram angulação colo-diáfise do metacarpo > 30° para os II e III metacarpos e > 40° para o V metacarpo, encurtamento ≥ 5mm, desvio rotacional e o desejo do paciente de não utilizar imobilização gessada. No pós-operatório imediato, os pacientes permaneceram sem imobilização e orientados a mobilizar os dedos conforme tolerância. Todos os pacientes ficaram com mobilidade ativa total > 240° e retornaram às suas antigas ocupações. Todas fraturas consolidaram e não houve reintervenções. Discussão As grandes vantagens da técnica com parafuso sem cabeça são sua baixa morbidade, estabilidade suficiente para não precisar de imobilização externa e reprodutibilidade com baixo custo. Conclusão Esta é uma técnica fácil, rápida, e que apresenta ótimos resultados para o tratamento cirúrgico das fraturas deslocadas do colo dos metacarpos.

The study of bone and horn produced items often causes great difficulties for researchers, since it is difficult to determine accurately the true functional purpose of an artifact. In some cases, for example in such as we will describe in the paper, this problem can be solved using ethnographic data. One of the most numerous categories of finished produced items made of organic raw materials is known in the Soviet, and later in Ukrainian, scientific literature under the term ‘rashpil’ (rasp). The raw materials for these artifacts were mostly long (metatarsal, metacarpal, and bones of gaskin), less often flat (mandibular), bones of large domestic animals like horse and ox. Less often, deer antlers were used for these purposes. Tools made from the long bones of large mammals were usually first made plane pressing the diaphysis. One or more anatomical sides of the bone were processed, preserving the epiphysis or making it partially or completely plane. In the latter case, the shape of the produced item was close to a parallelepiped. A characteristic feature of all these tools, regardless of the raw material and the degree of modification, are specific traces on the work surface – a series of parallel or chaotic lines of notches of subtriangular shape. They are applied, obviously, by some thin sharp tool. In the case when the ‘rashpils’ were made of metapodia, the tools with one, two, three, or four working surfaces can be found. A significant number of such artifacts were found in a broken, apparently in the process of operation, form. We know about cases of repeated use of one tool when after it lost the necessary work characteristics, the working surface was made plane again and reused. Such tools come from many ancient sites of the Northern Black Sea region and Scythian settlements outside the Northern Black Sea region. For a long time, they were mistakenly considered tools for processing ceramics, bone, tanning of hides, and even stone grinding. Their real purpose, as anvils to put teeth into serrated sickle blade sections, was established after analyzing large amounts of ethnographic data.

Background: Diaphyseal fractures of the tibia currently account for approximately 2% of all fractures presenting to orthopedic surgeons. Epidemiology has changed markedly during the last two decades with overcrowding and related to improved road safety. In comparison to young population majority of these fracture occur predominantly in females as compared to males in old population. Objectives: To determine the outcome of diaphysis fractures of tibia in elderly patients Methods: This study was carried out in department of orthopaedic Jinnah hospital Lahore from 2014-2017. One hundred and twenty patients both males and females in the age range of 65 to 80years, having diaphyseal fractures of tibia were included in the study. The patients with poly-trauma and with peri-prosthetic fractures were excluded from the study. After detailed medical history, clinical examination, the x-rays of tibia fibula AP and Lateral views including joint above and below were done to determine the configuration of the fracture. Each patient was followed at 1st, 2nd and at 6th week and then at 3rd month, 4th month, 6th month and later at 1 year. Data was entered and analyzed in SPSS ver: 21.0 and was presented and frequency and percentages. Cross tabulation was done for open and closed fracture for outcome and Chi Square test was used to assess statistical significance with p value of ≤0.05. Results: 62.5% were females and 37.5% were males with mean age of 72 + 5.45 years. The mode of injury in most of the patients was slip and fall 85% and 70 % of patients had closed fractures. Reamed intra medullary nailing was done in 80 patients and 25 patients with open fracture were treated with external fixator. In the remaining 5 patients we applied the POP cast. Nonunion was labeled at 9 months and was seen in 10.0% of patients while the delayed union was seen in 33.0% (40) of the patients. Among the patients who had nonunion 5 patients were treated with intramedullary nailing and 7 patients were treated with external fixator. Infection was seen in 10.0% (12) of patients and this happened in the patient with open fracture. No patient was lost in follow-up during the study. Overall mortality rate was 30% in the 1st year.

We report the peculiar case of a parosteal osteosarcoma arising beneath the periosteum in a 12-year-old boy. He complained of difficulty in left knee flexion. Plain radiography showed a uniformly dense mineralized mass in the bone cortex and parosteal ossified nodules at the metaphysis and diaphysis of the left distal femur. Periosteal reaction was not evident. Uniquely, plain radiography had a smooth outline and revealed gradually thickening mass toward the center. Histologically, the tumor showed a proliferation of spindle-shaped cells with parallel-oriented dense bone trabeculae and hyaline cartilaginous tissue disclosing mild atypia. The periosteum was inverted along the polypoid mass, but there was no periosteum at the top. Immunohistochemically, the spindle cells, including those at the top of the polypoid mass, and cartilaginous cells were positive for MDM2 and CDK4. MDM2 gene amplification was detected in these cells by fluorescence in situ hybridization. Despite the peculiar feature of plain radiography, the lesion was diagnosed as parosteal osteosarcoma. This case report presents a case of parosteal osteosarcoma arising beneath the periosteum, although it is postulated to arise in the outer layer of the periosteum. The unique radiographic findings in this case suggest an association of parosteal osteosarcoma with vigorous bone growth before closure of the growth plate.

Midshaft clavicle fractures represent about 4% of all fractures in the emergency department. Non-operative treatment of displaced midshaft clavicle fractures (DMCF) can result in a relatively high non-union rate. Several operative techniques, including intramedullary fixation (IMF) using elastic stable intramedullary nailing (ESIN), have therefore been established. IMF through the medial approach is less suitable for fractures of the lateral diaphysis. IMF of DMCF of the lateral diaphysis through a lateral approach can be an alternative approach for these fractures. The aim of this study is to describe the technique of IMF from the lateral side and to present the functional outcome and complications. A retrospective cohort study was performed. All patients with a traumatic DMCF treated with IMF using ESIN through a lateral approach between 2014 and 2019 were included. Endpoints were the functional outcome (QuickDASH, Subjective Shoulder Value (SSV)), pain (numeric rating scale (NRS)), daily impairment (activities of daily living (ADL)), complications and implant removal. Forty out of 43 patients were available for follow-up. Mean follow-up was 37 months. Mean age was 24 years (range 13–70). The median QuickDASH score was 0 (IQR 0.0–0.0) and the median SSV was 100 (95–100). The median ADL score was 1 (1–4) and the median NRS was 0 (0–0). No non-union occurred. Implant related irritation occurred in 11 patients (27.5%). Implants were removed in a total of 38 (95%) patients; in 10 cases due to irritation, in 28 cases routinely or on patient’s request. IMF of DMCF of the lateral diaphysis through a lateral approach leads to excellent functional results and seems to be a suitable option for internal fixation. However, as with IMF from the medial side, it is not without complications and implant-related irritation.

It has been shown in the paper thathe action of gravitational overloading results in considerable chnges of the strength characteristics of the rat humeral bones that are dependent on age, duration and experimental conditions., В работе показано, что действие гравитационной перегрузки приводит к весомым изменениям прочностных характеристик плечевых костей крыс, зависящих от возраста, продолжительности и условий эксперимента., У роботі показано, що дія гравітаційного перевантеження призводить до вагомих змін міцнісниххарактеристик плечових кісток щурів, які залежать від віку, тривалості та умов експерименту.

The aim of the study is a comparative analysis of the linear parameters of the length and width of the diaphysis of the middle phalanges in children and adolescents of Tajikistan and Western India, and also the possibility of using these linear parameters to establish the age of children of the compared ethnic groups. On 325 radiographs of the right hand in male children and adolescents of the Kanibadam region of the Republic of Tajikistan and the city of Mumbai (Western India) at the age of 6-17 years, the length of the middle phalanges and the width of their diaphysis were determined. To determine the relationship between the age of children of the compared ethnic groups and the linear parameters of the length and width of the shaft of the phalanges, Spearman's nonparametric correlation coefficient was used. Comparative assessment of the values ​​of indicators by age was carried out by the method of parametric and non-parametric analysis. In boys of Tajikistan, the closest correlation was established between the age of children and the length of the middle phalanx of the third finger, while in their Indian peers this ratio was determined evenly for the II-IV fingers of the hand. The width of the diaphysis of the phalanges of the fourth finger increased most significantly with age in boys of Tajikistan, and in the Indians, the width of the third finger, the smallest increase in the width of the diaphysis in the compared groups was determined for the phalanges of the second finger. The linear parameters of the middle phalanges of the hand can be used to identify the age of children and adolescents in Tajikistan and Western India at the age of 6-17 years. For Tajik children, the best predictor of age is the linear parameter of the length of the middle phalanx of the index, and for their Indian peers, the length of the middle phalanx of the II-IV fingers is equally.

The aim of the study is to establish ethno-territorial differences in the linear parameters of the proximal phalanges of the fingers in children and adolescents of the male sex of Tajikistan and Western India, regression equations that allow determining the nature of the dependence of the age of the examined and linear sizes of phalanges. On 366 radiographs of the right hand in children and adolescents aged 6-17 years from Tajikistan and India (Mumbai), the length of the proximal phalanges and the width of their diaphysis were measured. To determine the relationship between the age and the length, as well as the width of the diaphysis, Spearman's nonparametric correlation coefficient was used, because the age distribution does not correspond to normal. One-way ANOVA demonstrates the statistical significance of the increase in the length and width of the diaphysis of the proximal phalanges in boys and young men of Tajikistan and India with age, but the growth of these bones is uneven. For both Tajik and Indian boys, the closest correlation with age was found for the length of the second finger phalanx. It was found that in children in the smallest regions compared, the correlation was determined between their age and the length of the phalanx of the fifth finger. The length of the phalanx of the third finger increased most significantly with age in boys of the compared ethnic groups. The smallest height in length was determined for the phalanx of the fifth finger in boys in India and for the phalanx of the first finger in adolescents in Tajikistan. The maximum growth of the diaphysis in width was observed in the phalanx of the second finger, the smallest in the phalanges of the first and fifth fingers. The highest reliability was found with the length of the phalanx of the second finger. For Tajik boys, the parameters of the length of the phalanges of the III and IV fingers also have a correlation coefficient, therefore, they can be used to identify their age.

DNA analysis of Second World War skeletal remains is challenging because of the limited yield of DNA that is usually recovered. Recent forensic research has focused on determining which skeletal elements are superior in their preservation of DNA, and little focus has been placed on measuring intra-bone variability. Metatarsals and metacarpals outperformed all the other bones in DNA yield when analyzing all representative skeletal elements of three Second World War victims, and intra-bone variability was not studied. Soft-tissue remnants were found to contribute to higher DNA yield in trabecular bone tissue. Because metatarsals and metacarpals are composed of trabecular epiphyses and a dense diaphysis, the goal of this study was to explore intra-bone variability in DNA content by measuring nuclear DNA quantity and quality using the PowerQuant System (Promega). A total of 193 bones from a single Second World War mass grave were examined. From each bone, DNA was extracted from the compact diaphysis and from both spongy epiphyses combined. This study confirms higher DNA quantity in epiphyses than diaphyses among all the bones analyzed, and more DNA was obtained from metacarpal epiphyses than from metatarsal epiphyses. Therefore, whenever the possibility for sampling both metacarpals and metatarsals from skeletal remains exists, collecting metacarpals is recommended. In cases in which the hands are missing, metatarsals should be sampled. In any case, epiphyses are a richer source of DNA than diaphyses.

Introduction. Systemic perioperative vancomycin may not provide sufficient prophylactic target-site concentrations in the prevention of prosthetic joint infections. Intraosseous vancomycin potentially provides high target-site concentrations. The objective of the present study was to evaluate the local bone and tissue concentrations following tibial intraosseous vancomycin administration in a porcine model. Methods. Eight pigs received 500 mg diluted vancomycin (50 mg/mL) through an intraosseous cannula into the proximal tibial cancellous bone. No tourniquet was applied. Microdialysis was applied for sampling of vancomycin concentrations in adjacent tibial cancellous bone, in cortical bone, in the intramedullary canal of the diaphysis, in the synovial fluid of the knee joint, and in the subcutaneous tissue. Plasma samples were obtained as a systemic reference. Samples were collected for 12 h. Results. High vancomycin concentrations were found in the tibial cancellous bone with a mean peak drug concentration of 1236 (range 28–5295) µg/mL, which remained high throughout the sampling period. The mean (standard deviation) peak drug concentration in plasma was 19 (2) µg/mL, which was obtained immediately after administration. Peak drug concentration, time to peak drug concentration, and area under the concentration–time curve were within the same range in the intramedullary canal, the synovial fluid of the knee, and the subcutaneous tissue. Conclusion. Tibial intraosseous administration of vancomycin provided high concentrations in tibial cancellous bone throughout a 12 h period but with an unpredictable and wide range of peak concentration. The systemic absorption was high and immediate, thus mirroring an intravenous administration. Low mean concentrations were found in all the remaining compartments.

Background: Fractures of the distal femoral physis are the most common physeal fracture sustained by skeletally immature dogs. Reduction and stabilization of these fractures can sometimes be achieved through closed reduction, primarily in fractures that are nominally displaced. Circular external fixator constructs have been used to assist in indirect, closed reduction of fractures at other anatomic locations in dogs and this report describes application of this method to reduce a displaced Salter-Harris type II fracture of the distal femur in a 1-year-old dog. Case Description: A 1-year-old female spayed Akita was referred for treatment of a Salter-Harris type II fracture of the right distal femur. The epiphyseal segment was laterally and slightly caudally displaced. Multiple attempts to manually reduce the fracture during surgery were unsuccessful, so a two-ring circular external fixator construct was applied to facilitate distraction and reduction. The construct was applied by placing a medial-to-lateral Kirschner wire in both the mid-femoral diaphysis and in the distal femoral epiphysis. Distraction of the construct provided sufficient separation of the fracture segments to facilitate near anatomic reduction. The fracture was stabilized with two percutaneously placed Steinmann pins placed in Rush fashion. Radiographic union was confirmed 5 weeks after surgery. The dog was not lame and was bearing more weight on the right pelvic limb, as assessed using force plate analysis, 9 months following surgery. Goniometric measurements of stifle range of motion and thigh muscle circumference were similar between the pelvic limbs. Conclusion: Application of a two-ring circular construct would appear to be useful to facilitate closed reduction and percutaneous stabilization of distal femoral physeal fractures.

Purpose To compare the likelihood of spiral fracture of the humerus using torsional load to failure after intraosseous biceps tenodesis at the position of the arthroscopic suprapectoral tenodesis versus the subpectoral meta-diaphyseal location. Methods Eight matched pairs of humeri were dissected. Unicortical tenodesis holes were drilled, either at the bottom of the bicipital groove (group 1) or just below the pectoralis major tendon insertion (subpectoral) in the humeral diaphysis (group 2). Tenodesis was performed in a 7-mm bone tunnel, with suture fixation distal to this site using 2 separate 2-mm holes, secured with No. 2 polyester suture. Each humerus was potted in plaster and mounted to a hydraulic torsional load frame, consistent with previously validated models for creating humeral spiral fractures. External rotation torque was applied to each humerus distally until fracture occurred. The paired t test was used to compare the 2 groups. Results Fracture occurred at the subpectoral cortical drill hole in all 8 specimens in group 2. In group 1, only 2 fractures occurred through the tenodesis hole, with spiral fracture resulting in the diaphysis of the humerus in 6 of 8 specimens. Average torque to failure measured 31.35 Nm in group 1 and 25.08 Nm in group 2; the difference was statistically significant (P Conclusions Subpectoral cortical drill holes for biceps tenodesis were shown to be a stress riser for humeral spiral fracture. Suprapectoral cortical drill holes were shown to be significantly less of a stress riser. The amount of torque required to fracture the humerus through the subpectoral drill holes was less than with the suprapectoral drill holes. Only 2 fractures occurred through the suprapectoral tenodesis holes, and significantly more torque was required to create these fractures. Clinical Relevance Clinically, the difference between suprapectoral and subpectoral tenodesis fracture potential should be considered when selecting a tenodesis location.

Introduction Osteoid osteoma (OO) is a common tumor of the diaphysis of long bone, where the reported incidence is up 10% of all benign bone tumors. Its presence in flat bone is seldom mentioned in literature and can be misleading when the bone involved is in proximity to a zone of wide variety of possible pathology. We report a case of a young patient with OO in a very rare location of the body -the scapular neck - that was misdiagnosed for a long period of time before receiving adequate therapy. Case report A 20-year-old female patient presented to the clinic with chronic left shoulder pain. During the past 2 years, she received medical and physical therapy, to deal with different diagnosis such as cervical spine pathology, muscular spasm, and rotator cuff disease. However, she did not improve. At time of presentation to our clinic, radiographs of the shoulder were done and turned to be inconclusively normal. After negative magnetic resonance imaging of the cervical spine, a computed tomography scan of the shoulder was done and showed a round well-defined lesion localized in the scapular neck with a focal lucent nidus within surrounding sclerotic reactive bone measuring 8.5 mm in largest diameter, compatible with OO. Bone scan showed increased uptake. The patient was given aspirin in an intention to test and treat. The patient had dramatic pain relieve at first, which confirmed the diagnosis of OO. But then, pain became unremitting, so a decision was made for radiofrequency ablation of the lesion which gave excellent results. Conclusion OO is a common benign neoplasm with high variable clinical picture and anatomic localization. Despite being more common in long bone, flat bone OO localization should be always kept in mind. Careful history and physical examination should be done for each patient presenting with unexplained pain; night pain should always raise suspicion of this condition. Radiographs are not always conclusive, and the patient with high suspicion of this condition should undergo more investigation to make the diagnosis.

Bone marrow is the principal site of hematopoiesis in mammals. Amphibians were the first phylogenetic group in vertebrates to acquire bone marrow, but the distribution of hematopoietic cells in the bone marrow of the primitive frog, Xenopus laevis (X. laevis) has not been well documented. The purpose of this study was to perform a histological investigation of the distribution of hematopoietic cells in femoral bone marrow at various stages of development in X. laevis. Hematopoietic cells showed preferential distribution on the endosteal surface of cortical bone throughout all stages of development, from tadpole to aged frog. In mature frogs, hematopoietic cells appeared at the boundary between the epiphysis and the bone marrow. The distribution of hematopoietic cells around the blood vessels was limited to a small number of vessels in the bone marrow. Abundant adipose tissue was observed in the bone marrow cavity from the tadpole stage to the mature frog stage. Hematopoietic cells showed preferential distribution in a belt-like fashion on the surface of newly-formed bones in a bone regeneration model in the diaphysis of X. laevis. These results indicate that the distribution of hematopoietic cells in bone marrow in X. laevis differs from that in mammals, and that the bone marrow of X. laevis constitutes a useful model for exploring the mechanism underlying the phylogenetic differentiation of bone marrow hematopoiesis.

Introduction Proximal Tibial meta-diaphyseal fractures are challenging injuries because of subcutaneous anteromedial surface of bone and frequent soft tissue complications. Good management requires stable fixation with minimal soft tissue handling. Locking compression plate (LCP) applied as an external fixator fulfills these criteria and can be an important tool in the armamentarium of an orthopaedic surgeon. Aim: To study the clinical, functional and radiological outcome of comminuted fractures of metaphysis and diaphysis proximal tibia treated by stainless steel bridging plate in skeletally mature patients. Materials and Methods: This was a prospective study conducted from August 2013 to August 2020 at the Gajra Raja Medical college Gwalior with a 6month follow-up in skeletally mature patients with post-traumatic comminuted fractures of metaphysis and diaphysis of proximal tibia fractures were included. Patient were evaluated retrospectively interms of union, maintenance of reduction, complications and final outcome using KSS (Knee society scoring) for proximal fractures.Results: Following all principles of fracture reduction, union was achieved in all patients with mean time to radiological union being 20 weeks. The mean Range of Motion (ROM) was 106 degrees with According to KSS results were excellent in 28 patients (41%), good in 26 (38%), fair in 15(21%) 6 patients developed complications in the form of infection during the course of our study, but were completely treated by the end of the study. Conclusion: We found this technique to be more biological, simple to do surgery, effective in maintaining reduction till union, more patient friendly in comparison to traditional large, bulkyfixators and with minimal complications.

DNA testing of human bones is performed for identification when there is no remaining soft tissue, which often means the samples are old or environmentally compromised. Under these circumstances, it can be difficult to obtain a STR DNA profile. It is important to recover the highest quantity and quality of DNA for STR typing. This study compared the DNA recovery and STR profiles from five anatomical locations in five femora and five tibiae. These locations include the proximal metaphysis, proximal diaphysis, mid-diaphysis, distal diaphysis, and distal metaphysis. Twenty-five femur samples and 25 tibia samples were analyzed using the Qiagen Investigator Quantiplex Pro RGQ Kit for quantitating the extracted DNA and the Qiagen Investigator 24plex QS Kit for STR DNA typing. The highest DNA recovery of the five regions tested in both the femur and the tibia was from the midshaft diaphysis. The femur samples resulted in a significantly higher DNA recovery than the tibia samples as analyzed using a Kruskal-Wallis test (P = 0.002103). The midshaft diaphysis and distal diaphysis yielded the most complete STR DNA profiles in the femora, while the distal and proximal diaphysis yielded the most complete STR DNA profiles in the tibiae. There was no correlation between the amount of DNA recovered and the completeness of the STR DNA profile produced with low template extracts in this study.

Introduction: Knowledge of nutrient foramina is important in surgical procedures. Objective of present study is to know the number, location and direction of nutrient foramina in diaphysis of humerus and to test the significant difference of total length and foraminal index on right and left side separately. Materials and Methods: Total 100 dried humerii of unknown sex (52 of right and 48 of left side) were taken for present study. The identification of nutrient foramen was confirmed with the help of magnifying lens and metallic wire. The total length of humerus and distance of nutrient foramen from proximal end of humerus was measured by sliding caliper and osteometric board. Foraminal index was also calculated. Results: All the examined bones showed single diaphyseal nutrient foramen. Majority of foramina (81%) were present on middle 1/3 of anteromedial surface of shaft of humerus. The direction of these foramina was similarly found in all bones i.e. towards the elbow joint. There were no significant differences between right and left side for total length and foraminal index. Conclusion: An accurate knowledge of the location of nutrient foramina is important in surgical procedures like reduction of fracture, bone grafting and microsurgical vascularized bone transplantation. Keywords: Humerus, Nutrient foramina, Number, Location, Direction, Foraminal index.

Higher percentage of the nutrient foramina on femur was double while tibia and fibula showed single nutrient foramina. We studied the number, size, direction and foraminal index of diaphysis nutrient foramines of femur tibiae & fibulae in manner in which other authors studied. For the study, 450 dry bones (150 femora, 150 tibiae and 150 fibulae) of adult subjects of unknown sex & age were used from the Anatomy Museum of Government Medical College Miraj & Other medical colleges in Maharashtra, India. Of the 150 femora, tibiae & fibulae dominant foramina were 120(61.54%), 67(42.14%) & 32(20.38%) respectively and secondary foramina were 75(38.46%), 92(57.86%) & 125(79.62%) respectively. This information will be of great importance to orthopedician surgeons performing surgical procedures of the lower limb fractures. Aim and Objective: A detailed study was conducted for: Number and size of nutrient foramina in human lower limb typical long bones; Direction of nutrient foramina; Foraminal index. Keywords: Femur, Fibulae, Foraminal index, Nutrient foramina, Tibiae, Typical lower limb long Bones.

OBJECTIVE Disrupted blood supply has been proposed as an underlying cause for delayed union in tibial shaft fractures (OTA/AO 42). Although tibial blood supply has been qualitatively evaluated, quantitative studies are lacking. The purpose of this project was to quantify the relative contribution of the endosteal supply to the tibial diaphysis. METHODS The superficial femoral artery of 8 fresh frozen cadaveric matched pair lower extremities was cannulated. The nutrient artery was ligated at its proximal branch point in experimental limbs. Pregadolinium and postgadolinium enhanced magnetic resonance imaging was performed with high resolution fat-suppressed ultrashort echo time magnetic resonance imaging sequences. Perfusion was assessed in 3 zones (outer, central, and inner cortex) for the proximal, middle, and distal diaphysis, respectively, using custom software to quantify and compare signal intensity between experimental and control limbs. RESULTS On average, the endosteal system supplied 91.4% (±3.9%) of the cortex and was the predominant blood supply for the inner, central, and outer thirds. The dominance of the endosteal contribution was most pronounced in the inner two-third of the cortex, with more than 97% loss of perfusion. Disruption of the nutrient artery also resulted in 76.3% (±11.2%) loss of perfusion of the outer one-third of the cortex. CONCLUSION This quantitative study revealed a predominance of endosteal blood supply to all areas (inner, middle, and outer thirds) of the tibial diaphyseal cortex. To prevent delayed bone healing, surgeons should take care to preserve the remaining periosteal vascular network in fracture patterns in which the nutrient artery has likely been disrupted.

The Ewing's sarcoma family of tumors are aggressive malignant small round blue cell tumors of undifferentiated mesenchymal origin. Skeletal Ewing's sarcoma is a common entity that classically involves the diaphysis of the long bones, pelvis, ribs, and sacrum. Extraosseous Ewing's sarcoma (EES) is rare, most commonly presenting as a paravertebral mass lesion. Its manifestation as an anterior epidural mass lesion with extension along brachial plexus is an even rarer phenomenon. A 25-year-old male presented with neck stiffness and progressive weakness of the bilateral upper and lower limbs. Magnetic resonance imaging of the cervical spine revealed an anterior epidural mass lesion compressing the cervical cord and extending along the right brachial plexus, suggesting imaging differentials of EES and lymphoma. The patient underwent laminectomy with gross tumor resection, and histopathology confirmed a diagnosis of EES. EES should be kept in the differential diagnosis of anterior epidural mass lesions in young adults, specifically when the lesion shows extension along multiple neural foramina and nerve plexus.

The results of blocked intramedullary osteosynthesis (BIOS) in 50 patients with fractures of the distal and diaphysis of the tibia are presented. Blocked intramedullary osteosynthesis is a reliable and predictable method for the treatment of diaphyseal fractures of the tibia, which allows the restoration of limb function in the shortest possible time in most patients.

Metastatic disease is the most common pathologic cause of bone destruction, and the upper extremity is frequently involved. This location presents many surgical challenges, but there have been several recent implant and technique-related advances that have improved outcomes. Patients can be treated nonsurgically, with radiation or with surgery, depending on patient characteristics, signs/symptoms, primary diagnosis, location, and extent of bone destruction. Most locations in the upper extremity besides the humerus can be treated nonsurgically or with radiation. This is also true of the humerus, but when surgery is indicated, plate fixation is acceptable when adequate proximal and distal cortical bone is present for screw purchase. Intramedullary nailing is used frequently in metastatic humeral disease as well, especially in the diaphysis. When extensive destruction or disease progression precludes internal fixation, a resection with endoprosthetic reconstruction can be considered. Oncologic hemiarthroplasty endoprosthetics still have a role, but reverse shoulder designs are beginning to show improved function. Humeral prosthesis designs are continuing to improve, and are becoming more modular, with custom implants still playing a role in certain challenging scenarios.