Open Access
Review
Table 3
Detailed data on potential risk factors for stress shielding in RSA.
| Study | Sample | Age (years) | Risk factor | Outcomes | FU (months) |
|---|---|---|---|---|---|
| Yokoya et al. [35] | 135 shoulders | 77.8 | – Type of stem (length) | – Predictors of stress shielding: long stems, cementless stems, larger proximal FR and larger metaphysis diameters | 34.6 |
| – Type of stem (thickness) | – FRprox > 0.7 is an independent predictors of stress shielding | ||||
| – Type of fixation | – Stress shielding: NSA 155° (26.9%), NSA 135° (59.6–93.5%) | ||||
| – Filling ratio | – Stress shielding was seen in 50.4% of the shoulders | ||||
| – Gender | |||||
| Nourissat et al. [36] | 19 shoulders | 74.6 | – Filling ratio | – Low rate of stress shielding: press-fit ovoid stem of 100 mm length | 72 |
| – Type of fixation | – No correlation between the filling ratio and resorption of the bone | ||||
| – Type of stem (length) | – Lower rate of stress shielding: humeral neck-shaft angle of 145° | ||||
| Erickson et al. [37] | 577 shoulders | Short-stem: 68.5 | – Type of fixation | – No differences on stress shielding between short inlay press-fit stem and standard press-fit stem | Minimum 2 y |
| Short-stem: 220 | Standard-stem: 69.4 | – Filling ratio | – There is an ideal FRmet around 60–70% to minimize stress shielding | ||
| Standard-stem: 357 | – Type of stem (length) | – Short (60–65 mm) stems lead to comparable rate of stress shielding compared with standard-length (111–147 mm) stems | |||
| – Type of stem (design) | |||||
| Giordano et al. [11] | 76 shoulders | Onlay: 76.2 | – Type of fixation | – Higher rate stress shielding: onlay with 145° neck-shaft angle cohort | Onlay: 46.8 |
| Onlay: 34 | Inlay: 76 | – Type of stem (length) | – Lower rate of stress shielding: long-inlay straight stems | Inlay: 36 | |
| Inlay: 42 | – Type of stem (design) | – Lower rate of stress shielding: humeral neck-shaft angle of 155° (7.1%) versus 145° (17.6%) | |||
| Kim et al. [12] | 104 shoulders | HFR: 72.1 | – Filling ratio | – Patients with low FR stems with autogenous bone grafting had significantly less humeral stress shielding than patients with high FR and press-fit stem | HFR: 13.5 |
| HFR: 53 | LFR: 73.5 | – Type of fixation | LFR: 13.2 | ||
| LFR: 51 | |||||
| Kramer et al. [13] | 51 shoulders | All: 74 | – Type of fixation | – Not correlation of higher FRdist with severe stress shielding | 27 |
| Cemented: 34 | Cemented: 74.4 | – Filling ratio | |||
| Cementless: 17 | Uncemented: 74.1 | ||||
| Lopiz et al. [14] | 68 shoulders | Cemented: 78 | – Type of fixation | – Stress shielding: 30.4% of uncemented group | Cemented: 37.8 |
| Cemented: 45 | Uncemented: 80 | – Filling ratio | – Not correlation of FRdiaph with stress shielding | Uncemented: 26.5 | |
| Cementless: 23 | |||||
| Valenti et al. [15] | 24 shoulders | 68.7 | – Type of fixation | – Signs of stress shielding appeared exclusively in non-cemented stems | 44.7 |
| Cemented: 5 | |||||
| Cementless: 19 | |||||
| Mazaleyrat et al. [4] | 140 shoulders | Cemented: 74.5 | – Type of fixation | – Proximal humeral osteolysis: inlay-type RSA with cementless stems | Cemented: 9.6 y |
| Cemented: 70 | Cementless: 75.3 | – Type of stem (design) | – Proximal humeral osteolysis can in part be attributed to stress shielding | Uncemented: 8.9 y | |
| Cementless: 70 | – Signs of stress shielding, such as osteopenia, was only in cementless (89%) | ||||
| Nagase et al. [31] | 14 shoulders with rheumatoid arthritis | 74 | – Type of fixation | – Stress shielding: 21.4% of humeral cemented stems | 57.9 |
| Polisetty et al. [16] | 92 shoulders | Onlay: 74.8 | – Type of stem (design) | – Stress shielding, onlay-style had more instances of GT (73.9%) and calcar (39.1%) resorption | Onlay: 29 |
| Onlay: 46 | Inlay: 73.2 | – Inlay-style prosthesis: better prevention of | Inlay: 31 | ||
| Inlay: 46 | humeral stress shielding | ||||
| Abdic et al. [17] | 124 shoulders | 74 | – Type of fixation | – Small stems (≤90 mm) are implicated in a higher incidence of malpositioning with high endocortical contact | n/a |
| – Filling ratio | – Smaller malaligned stem (≤90 mm): higher rate of endocortical contact distally, which associated with stress shielding | ||||
| – Type of stem (length) | – Short stems (<94 mm) may decrease stress shielding | ||||
| – Alignment of stem | |||||
| Brolin et al. [18] | 120 shoulders | 70.6 | – Type of fixation | – Uncemented stems had significantly more internal stress shielding | 35.2 |
| Cemented: 49 | – Gender | – Neither age nor gender had a correlation with stress shielding | |||
| Cementless: 71 | |||||
| Denard et al. [39] | 119 shoulders | Cemented: 71.1 | – Type of fixation | – Proximal stress shielding was more common with press-fit fixation | Press-fit: 36.1 |
| Cemented: 26 | Cementless: 69.3 | – Type of stem (length) | – Proximal lateral stress shielding: 25% in cemented and 68% press-fit group | Cemented: 36.8 | |
| Cementless: 93 | – Standard length stems (111–147 mm) can lead to stress shielding | ||||
| Inoue et al. [20] | 48 shoulders | 76.5 | – Gender | – Female gender and onlay-type stem were significant independent risk factors for grade 4 bone resorption (GT, lateral diaphysis and calcar), due to stress shielding | 18.5 |
| – Type of stem (design) | – The mechanism of bone resorption after RSA may be related to stress shielding and polyethylene wear | ||||
| Aibinder et al. [21] | 100 shoulders | 68.2 | – Type of stem | – GT stress shielding: 18.5% in cementless short humeral component | 3.8 y |
| TSA: 35 | |||||
| RSA: 65 | |||||
| Merolla et al. [22] | 74 shoulders | Inlay: 75.8 | – Type of stem (length) | – The standard stem (inlay-design) showed higher stress shielding and higher rate of GT resorption | Inlay: 35.1 |
| Aequalis II: 36 | Onlay: 74.7 | – Type of stem (design) | – Stress shielding: NSA 155° (cortical thinning, 26.9%; spot welds, 11%), NSA 145° (cortical thinning, 26%) | Onlay: 29.1 | |
| Ascend flex: 38 | |||||
| Raiss et al. [38] | GI: 150 TSA | GI: 68 | – Filling ratio | – Stress shielding: higher in the uncemented group | GI: 32 |
| GII: 77 RSA | GII: 72 | – Type of fixation | – Stress shielding: 35% of stems, with high bone adaptations in 17% | GII: 28 | |
| – Type of stem (length) | – FR ≥ 0.8 increases the rate of stress shielding | ||||
| – Stress shielding in 97% in RSA in stems with 66–94 mm of length | |||||
| Harmsen and Norris [24] | 232 shoulders | 68.2 | – Type of fixation | – Internal stress shielding is observed to the coated diaphyseal press-fit humeral stem | 26.4 |
| – Type of stem (length) | – Internal stress shielding of 97.4% in the early post-operative period | ||||
| Weber-Spickschen et al. [25] | 15 shoulders | 70 | – Type of fixation | – Stress shielding: 13.3% in cementless humeral stem | 43 |
| Cemented: 1 | |||||
| Cementless: 14 | |||||
| Al-Hadithy et al. [9] | 41 shoulders | 79 | – Type of stem | – Proximal humeral bone resorption: 10% in uncemented and hydroxyapatite coated humeral stem, due to stress shielding | 5 y |
| Wiater et al. [26] | 101 shoulders | Cemented: 71.95 | – Type of fixation | – Stress shielding: 7.8% in uncemented stems | Cemented: 37 |
| Cemented: 37 | Cementless: 72.47 | – Stress shielding and bone resorption: laterally at the metadiaphyseal junction | Cementless: 32.4 | ||
| Cementless: 64 |
Abbreviations: n/a, not applicable; FU, follow-up; y, years.
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