The relationship between stress shielding, bone density changes and implant migration, failure and fracture after total knee arthroplasty: A systematic review

IF 2 Q2 ORTHOPEDICS

Journal of Experimental Orthopaedics Pub Date : 2025-07-13 DOI:10.1002/jeo2.70350

Giulio Senesi, Giuseppe Barone, Salvatore Pinelli, Maria Scoppolini Massini, Raffaele Zinno, Domenico Alesi, Erika Pinelli, Laura Bragonzoni

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Abstract

Purpose

Total knee arthroplasty (TKA) represent a well-established treatment for advanced osteoarthritis. Despite advancements in implant design and materials, the impact of stress shielding on bone mineral density (BMD) and its relationship with implant migration, loosening, and fracture remains insufficiently explored. This study aims to evaluate the association between stress shielding, BMD changes, and implant outcomes after TKA.

Methods

A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Four major databases (MEDLINE (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science (WOS), EMBASE) were thoroughly reviewed.

Results

A total of 491 studies were initially identified, of which nine met the inclusion criteria and were included in the final review. Eight were randomised controlled trials, and one was a prospective observational study. All studies were conducted in clinical settings, comprising a total of 467 patients. BMD variations due to stress shielding were most pronounced during the first 6–12 months postoperatively. However, except for one isolated case, no direct correlation was identified between BMD changes caused by stress shielding and implant migration, loosening or fracture.

Conclusions

This systematic review highlights that variations in bone mineral density due to stress shielding are not directly correlated with implant failure, migration or loosening in TKA. Stress shielding remains a critical phenomenon, particularly in the early postoperative phases, emphasising the importance of optimised materials, fixation methods and implant designs to reduce bone loss and improve long-term stability. Due to its recognised occurrence in clinical practice, further in vivo studies would contribute to a better understanding of the stress shielding.

Level of Evidence

Level II, systematic review of studies.

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全膝关节置换术后应力屏蔽、骨密度变化与植入物迁移、失效和骨折的关系：系统综述

目的全膝关节置换术（TKA）是一种成熟的治疗晚期骨关节炎的方法。尽管在种植体设计和材料方面取得了进步，但应力屏蔽对骨矿物质密度（BMD）的影响及其与种植体迁移、松动和骨折的关系仍未得到充分探讨。本研究旨在评估应力屏蔽、骨密度变化和TKA后种植体预后之间的关系。方法按照系统评价和荟萃分析的首选报告项目（PRISMA）指南进行系统评价。四个主要数据库(MEDLINE (PubMed), Cochrane Central Register of Controlled Trials （Central), Web of Science (WOS)， EMBASE）进行了全面的审查。结果初步共纳入491项研究，其中9项符合纳入标准，纳入终评。其中8项为随机对照试验，1项为前瞻性观察性研究。所有研究均在临床环境中进行，共包括467名患者。应力屏蔽引起的骨密度变化在术后6-12个月最为明显。然而，除了一个孤立的病例外，没有发现应力屏蔽引起的骨密度变化与植入物迁移、松动或骨折之间的直接相关性。本系统综述强调应力屏蔽导致的骨密度变化与TKA种植体失败、迁移或松动没有直接关系。应力屏蔽仍然是一个关键现象，特别是在术后早期，强调优化材料、固定方法和种植体设计的重要性，以减少骨质流失和提高长期稳定性。由于其在临床实践中公认的存在，进一步的体内研究将有助于更好地理解应激屏蔽。证据等级：二级，系统评价研究。

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