Background/Purpose:

An increasing number of total joint replacement (TJR) procedures are performed as computer-assisted total joint replacement (CA-TJR). Effectiveness of computer-assisted total joint replacement (CA-TJR) compared to conventional TJR has been evaluated by multiple systematic reviews with conflicting results. We evaluated the quality of systematic reviews comparing CA-TJR to conventional TJR.  

Methods:

We searched MEDLINE, EMBASE, the Cochrane, and Epistemonikos to identify systematic reviews published through May 2017. One reviewer conducted title and abstract screening of all resulting citations. Full-text articles that met inclusion criteria were retrieved and assessed independently by two reviewers using the AMSTAR 2 tool (Shea et al., 2017). AMSTAR 2 has seven critical and 9 non-critical domains. Systematic reviews are rated as high (no critical or non-critical flaws), moderate (non-critical flaws only), low (1 critical flaw), or critically low quality (>1 critical flaw).

Results:

Of 384 citations originally identified, 38 systematic reviews were included (Figure 1). Based on the AMSTAR 2 tool, 37 studies were rated critically low and one study was rated low. The low rating was due to failure in meeting AMSTAR 2 criteria on the following critical domains (Figure 2): 37 (89%) reviews did not report the  protocol registration; 32 (84%) studies did not justify excluding individual studies; 27 (68%) studies did not account for risk of bias in primary studies when interpreting the results; 20 (52%) failed to use comprehensive literature search strategy; 17  reviews with meta-analyses failed to justify the use of appropriate methods for statistical combination of results from randomized controlled trials (48%) and non-randomized studies (44%), and 16 (42%) meta-analyses did not use satisfactory techniques to assess risk of bias of RCTs; and 16 (42%) studies failed to report publication bias. The non-critical weaknesses are shown in figure 3.

Conclusion:

Despite the large number of published systematic reviews about the relative effectiveness of CA-TJR, quality of these reviews was critically low, thus significantly weakening the conclusions derived from these reviews.

Figure 1: Flow Diagram of Study Selection

Figure 2

            Figure 3