Total joint arthroplasty of the hip and knee has become one of the most frequent and rewarding operations in orthopaedic surgery. Worldwide, more than one million such prostheses are implanted annually. With the steady rise in life expectancy, long-term complications related to implant loosening and peri-implant fractures are on the rise. Efforts to sustain and improve the clinical survival of total joint implants have thus generated great interest. The main challenge of implant integration by the surrounding bone is an adequate load transmission. Following implantation of a femoral stem, the load transmission is more distal in the femur. Due to the changed biomechanics and the stiffness of the implant, the periprosthetic bone reacts with a proximal periprosthetic osteopenia (“stress shielding”) (Fig. 88.1). Bone atrophy around the implant components is considered as a potential factor leading to aseptic component loosening limiting the survival of the prosthesis.